MIGRATION AND SEXUAL REPRODUCTIVE HEALTH (SRH)

Migration and SRHR is a very important and interesting research area not only because of the health challenges connected to it and the health inequalities resulting from it, but also due to the influence of norms and values in how migrants experience and practice sexuality and seek sexual and reproductive healthcare. Through our research during the past decades, we have explored prevalence and risk factors associated with sexual and reproductive health outcomes among migrant women in Sweden and other contexts, and their health seeking experiences. In our current research, we explore the role of multiculturalism, the norms and values among healthcare providers and migrant patients utilising sexual and reproductive healthcare.

Publications:

Birgitta Essén, Luce Mosselmans: How to ensure policies and interventions rely on strong supporting facts to improve women’s health: The case of female genital cutting, using Rosling’s Factfulness approach

International comparisons show that Swedes' values are liberal, individualistic and pro equality to a greater extent than other populations. This means that their values in sexual and reproductive health and rights (SRHR) can be quite different from the dominant values of other countries. These values are also evident in the Swedish laws, such as the right to deny sex between spouses. Swedish values are also evident in Swedish institutions, e.g. youth clinics where minors can receive sexual counseling and contraception without parental consent. Sweden is a multicultural country where many residents come from the Middle East region and Somalia, areas where commonly held values can stand in sharp contrast to those on which Swedish society, public health efforts and care are based. From previous research, we know that migrant women from these areas have poorer delivery outcomes, lower contraceptive use and more abortions than Swedish women. According to current policy documents, staff in reproductive healthcare are encouraged to incorporate gender equality perspectives, while at the same time providing culturally sensitive care. It has proved challenging for healthcare professionals to provide care in meetings with individuals with values that differ from those on which Swedish society is based. In the healthcare provider and patient appointment sensitive topics such as reproduction, sex and cohabitation can lead to tensions, misunderstandings and ultimately a deterioration in appropriate care. Research on how healthcare systems handle these challenges is scarce. One explanation for this may be that research questions include difficult topics to study in an academic discipline alone, and require knowledge from both medical and social science research, which we hope the proposed research environment will remedy.

The overall goal for the project is to contribute to improved care for migrants from the Middle East and Somalia by increasing the knowledge of how value conflicts and cultural change are to be managed in the health care sector.

Research questions:

• How and when do gender-related values change among newly arrived Middle East and Somali migrants?
• How could sexual and reproductive health (SRH) care be tailored, involving all relevant stakeholders, to best address value conflicts in clinical encounters with migrants?
• Can a participatory community based intervention involving the Swedish Somali diaspora change attitudes towards FGC among practicing families in Somalia? 

To answer these questions, the research program uses both quantitative and qualitative methods. The data will be collected via surveys and focus group discussions between healthcare providers and migrants from the Middle East and Somalia.

The project is interdisciplinary and conducted in collaboration between researches in Reproductive Health, Anthropology, Social Work and Norm Research. Both senior and junior researchers are included in the research environment, some with unique expertise based on their background in the Middle East and Somalia. The research will be co-produced with health care providers and migrants from the Middle East and Somalia.

Birgitta Essén, Professor
Andrey Tibajev, PhD
Lise Eriksson, Associate professor
Soorej Jose Puthoopparambil, PhD

Institute for Future Studies, Stockholm:
Pontus Strimling, PhD
Irina Vartanova, Researcher

Malmö University:
Aje Carlbom, PhD
Nada Amroussia, PhD student

Funding: VR (18 million SEK), Forte

The Swedish law guarantees for all residents the right to health and healthcare on equal terms. However, previous studies have shown that migrant women face structural and institutional barriers that often prevent them from accessing sexual and reproductive health (SRH) services. The little research on migrant youth sexual and reproductive health and rights (SRHR) has pointed out that youth access to SRH information and services is hampered by cultural barriers including the culture of honor and norms endorsing gender inequality. This suggests that culture has an important role in determining the ability of migrant youth to enjoy their sexual and reproductive rights. In the past few decades, “cultural humility” has emerged as one of the main paradigms addressing the issues of diversity and equality in healthcare settings as it can enhance cultural understanding between health care providers and services users.

Research questions:

The overarching aim of this study is to understand the facilitators and barriers of providing culturally appropriate youth SRH services in Sweden and explore the role that can be ascribed to cultural humility in addressing these barriers. The project has four specific aims:

• Examine how the concepts of cultural relativism, cultural competency, and cultural humility have been negotiated and incorporated in the public health policy in Sweden.
• Explore health care providers’ and counselors’ experiences of providing SRH services to migrant youth and their understandings of the complexity of engaging migrant youth with related services.
• a) Explore how middle eastern migrant youth construct their sexual embodiment and how they understand and negotiate the cultural meanings associated with the process of sexual embodiment, b) explore youth experiences when using SRH services and their understandings of factors that affect their use of these services.
•  Identify strategies and interventions to ensure the provision of culturally appropriate SRH services from multi-stakeholder perspective, with focusing on the role of cultural humility.

Birgitta Essén, professor
Soorej Jose Puthoopparambil, PhD

Malmö University:
Aje Carlbom, PhD
Nada Amroussia, PhD student

Funding: VR

Research questions

• How do Somali-born women perceive wellbeing, violence and their Swedish maternity care encounters in the light of long-lasting war?
• Why is that immigrant women face considerable challenges in obtaining sufficient level of reproductive health in secular healthcare settings?
• What does religion – and Islam specifically – got to do with these disparities in health?
• What are the risk factors, magnitude, attitudes, and prevention strategies regarding female circumcision among Somalis in Sweden?
• What happened with the ”deeply rooted” traditions, like female genital cutting, after migration to Sweden?
• What is the prevalence of induced abortion in different groups of migrants and non-migrants, and what are the barriers to equitable abortion care?
• What are the patterns of accessibility to contraception in different groups of migrants and non-migrants?

Major findings

• A large part of the Somalis in diaspora, including the newly arrived, are opponents of female circumcision, supporting social convention theory and proving that attitudes towards this practice can change.
• Islam offers a system of norms on reproductive health matters; yet not always observed by Muslims.
• Several informants use Islamic edicts to argue positively for use of contraception.
• Strategies related to maternity healthcare encounters, wellbeing and violence disclosure are upon arrival in Sweden shaped by political violence, with focus on inner resources and social networks for support and strength.
• Most Somali born women in Sweden have a pre-migrational experience from war-related violence. In the new context of Sweden a ”moving on” strategy  and social networks are instruments used to cope in the new society. Partner-violence was, however, not seen as a central theme after migration.
• Communication was a key role in encounters, at the antenatal and reproductive care clinics. Swedish midwives are not yet familiar with the fundamental differences between individualistic and the collective life systems in Sweden vs Somalia.
• Migrants have lower accessibility to contraception as compared to non-migrants.
• Second generation immigrant women have lower accessibility to contraception as compared to foreign-born and non- immigrant women.
• The organization of abortion care might hinder equitable abortion care.

Location: Sweden, EU 

Det övergripande syftet är att studera utrikesfödda kvinnors nyttjande av svensk eftervård och deras egna och deras partners syn på eftervården. Syftet är också att undersöka barnmorskors, läkares och beslutfattares erfarenheter, tankar och idéer om hur man skulle kunna planera för en eftervård med potential att nå fram till utrikesfödda kvinnor och tillgodose deras behov. 

Vården efter födseln behöver utvärderas och utvecklas när befolkningens sammansättning ändras och mer än en fjärdedel av barnaföderskor är födda i ett annat land än Sverige. Nya arbetssätt efterfrågas av barnmorskor för att kunna möta utrikesfödda kvinnors behov och erbjuda en jämlik vård. Utrikesfödda kvinnor är en heterogen grupp med både högre och lägre risk för graviditets- och förlossningskomplikationer. För att utveckla eftervården för de som bäst behöver den kommer vi identifiera riskgrupper och undersöka vad de själva tänker om vården efter förlossningen. Vi kommer också att intervjua barnmorskor, läkare och beslutsfattare angående deras syn på hur eftervården skulle kunna förbättras för utrikesfödda kvinnor på ett hållbart och kostnadseffektivt sätt. Resultatet kommer ligga till grund för interventionsutveckling och evaluering inom ramen för forskningsprogrammet EMMA (Enhanced Maternity care for migrant women - resarch to action).

Forskningsfrågor:

• I vilken omfattning tar utrikesfödda kvinnor del av vården efter födseln i Sverige?
• Vilka riskfaktorer finns för att utrikesfödda kvinnor ska utebli från efterkontrollen hos barnmorskan ca 4-16 veckor efter födseln?
• Vad tänker utrikesfödda kvinnor och deras partners om vården efter födseln? Vad har de för erfarenheter och vad önskar de att vården skulle innehålla?
• Hur skulle vården efter födseln för utrikesfödda familjer kunna förbättras på ett hållbart och kostnadseffektivt sätt?

Malin Berbers, doktorand
Erica Schytt, adjungerad professor, /KBH UU/ CKF Dalarna, leder EMMA-programmet 
Elin Ternström, lektor, Dalarnas Högskola
Helena Lindgren, docent, Karolinska institutet
Susanne Hesselman, Med Dr, CKF Dalarna

Forskningsbidrag: Region Gävleborg, RFR

Sweden receives a large number of asylum seekers and other groups of migrants in the world. Some of these migrants end up in detention centres. Most of the European countries use detention centres in order to facilitate deportation of migrants who have been captured.

The time spent in the detention centre often has a negative impact on a detainee as it affects his/her present and future life. The health status of the detainees, which is often sub-optimal, is worsened when they are detained. They need support to handle the stressful situation in the detention. In order to provide this support, an understanding of the detainee’s daily life is required. The detention systems in Sweden, Belgium, the Netherlands and Luxembourg (Benelux countries) were compared to identify good practices. However, the main focus was on the Swedish system. The main objective of the study was to identify factors which mitigate the harmful effect of detention on the health of detainees. This was a mixed-methods project.

The detainees considered detention as a prison and experienced lack of control over their own lives and desired for less restrictions within detention. They had had low Quality Of Life (QoL) scores with psychological domain having the lowest score. The support received from detention staff was the most significant factor that was positively associated the QoL. The detention staff expressed the need for better training, support and role definitions to provide better support for the detainees. The healthcare services provided in Swedish detention centres were found to be suboptimal, especially when compared to the Benelux countries. There were several collaborators in the project such as the Swedish Border police, national NGOs and the International Organization for migration (IOM). The project was conducted in close partnership with the Swedish Migration Agency (SMA), following a transdisciplinary approach, resulting in majority of the project recommendations being implemented by the SMA. Next stage of the project, to develop tools to support detention staff and health care providers, is currently being planned.

Soorej Jose Puthoopparambil, PhD

Magdalena Bjerneld, PhD

Sweden has received unaccompanied children since the end of 1980ths. During the period 1980 - 2010 around 11000 unaccompanied children arrived in Sweden. The tendency is that this group of children will increase in the future. In the beginning of 1990th the Somali children was the largest group and they still are, together with children from Afghanistan. The majority are boys but one third are girls. The majority of the children have received asylum and have therefore lived their fist years as young adults in Sweden

There exists research on how the local and regional system can support unaccompanied minors and challenges experienced by the healthcare providers and other staff working with the children. However, research on how the general public can support unaccompanied minors can be seldom found. In this ongoing project we explore how Swedish families support unaccompanied children and the try to facilitate their integration into the society. The project is in collaboration with Save the Children.

Magdalena Bjerneld, PhD

Soorej Puthoopparambil, PhD

During 1998-1999 we performed a study in Sweden where unaccompanied girls from Somalia were interviewed. They experienced great cultural differences concerning the expectations on girls. They had difficulties to learn Swedish and lack of trust in new people.

The overall aim with this study was to document and to analyse how a group of unaccompanied girls from Somalia looked back on their first years in Sweden as young adults. The objectives was to document how they have experienced the reception of the authorities, how they have been received by the Swedish health care system, how they self-rate their own health and how they have developed their social network in Sweden.

Through the project we found unaccompanied asylum seeking girls (UASG) need support from different groups of adults, ranging from the staff at the group homes to community members, including countrymen, to establish a good life in their new country. The UASG need understanding and knowledgeable staff that can support them through the initial period, when they do not have their parents close to them. All actors in the supporter network need more knowledge about the difficulties in war situations. Former Unaccompanied asylum-seeking children can assist newcomers as well as being informants to authorities in a new country. Both parties involved need to be open and willing to learn from each other.

For more information see article below.

Thesis: Arousell, Jonna. Sacred Ideals: Diversity and Equality in Swedish Reproductive Healthcare. Full text To DiVA

Thesis: Binder, Pauline.The Maternal Migration Effect: Exploring Maternal Healthcare in Diaspora Using Qualitative Proxies for Medical Anthropology. Full text To DiVA

Thesis: Byrskog, Ulrika. ’Moving On’ and Transitional Bridges: Studies on migration, violence and wellbeing in encounters with Somali-born women and the maternity health care in Sweden. Full text To DiVA

Thesis: Esscher, Annika. Maternal Mortality in Sweden: Classification, Country of Birth, and Quality of Care. Full text To DiVA

Thesis: Puthoopparambil, Soorej Jose. Life in Immigration Detention Centers: An exploration of health of immigrant detainees in Sweden and three other EU member states Full text To DiVA

Arousell, Jonna; Carlbom, Aje; Johnsdotter, Sara; Essén, Birgitta. Are 'low socioeconomic status' and 'religiousness' barriers to minority women's use of contraception? A qualitative exploration and critique of a common argument in reproductive health research. Ingår i Midwifery, s. 59-65, 2019.DOI Full text To DiVA

Arousell, Jonna; Carlbom, Aje; Johnsdotter, Sara; Essén, Birgitta. Does Religious Counselling on Abortion Comply with Sweden’s ‘Women‑Friendly’ Abortion Policies?: A Qualitative Exploration Among Religious Counsellors. Ingår i Sexuality & Culture, s. 1230-1249, 2019. DOI To DiVA

Arousell, Jonna; Carlbom, A.; Johnsdotter, S.; Essén, Birgitta. Are 'Low Socioeconomic Status' and 'Religiousness' barriers to minority women's contraceptive use in Sweden and Denmark?: A qualitative interrogation of a common argument in health research. Ingår i European Journal of Public Health, s. 121-121, 2018. Till DiVA

Arousell, Jonna; Carlbom, A.; Essén, Birgitta. Is multiculturalism bad for swedish abortion care?: Exploring the diversity of religious counselling in public healthcare institutions. Ingår i European Journal of Public Health, s. 122-122, 2018. DOI To DiVA

Arousell, J., Essén B, Johnsdotter, S. Carlbom, A. A Foucaultian Perspective on Encounters between Healthcare Providers and Muslim women in Swedish Reproductive Healthcare (manuscript).

Arousell, J., Carlbom, A., Johnsdotter, S. Essén, B. Does Religious Counselling on Abortion Comply with Sweden’s ‘Women‑Friendly’ Abortion Policies? A Qualitative Exploration Among Religious Counsellors. Sexuality & Culture 2019.

Arousell, J., Carlbom, A., Johnsdotter, S., Larsson, E., Essén, B. Unintended Consequences of Gender Equality Promotion in Swedish Multicultural Contraceptive Counselling: A Discourse Analysis. Qualitative Health Research, 2017: 27;1518-1528.

Bjerneld, Magdalena; Ismail, Nima; Puthoopparambil, Soorej Jose: Experiences and reflections of Somali unaccompanied girls on their first years in Sweden: a follow-up study after two decades. Part of International Journal of Migration, Health and Social Care, p. 305-317, 2018. DOI Full text To DiVA

Bjerneld, Magdalena. What has happened during the last two decades?: A follow up study of unaccompanied Somali girls in Sweden. Ingår i European Journal of Public Health, s. 101-101, 2018. DOI To DiVA

Bozorgmehr, K., Biddle, L., Rohleder, S., Puthoopparambil, S., Jahn, R.(2019). What is the evidence on availability and integration of refugee and migrant health data in health information systems in the WHO European Region?: Health Evidence Network synthesis report 66, Themed issues on migration and health, X.Health Evidence Network Copenhagen. To DiVA

Byrskog, Ulrika; Ahrne, Malin; Small, Rhonda; Andersson, Ewa et al. Rationale, development and feasibility of group antenatal care for immigrant women in Sweden: a study protocol for the Hooyo Project. Ingår i BMJ Open, 2019. DOI Uploaded full-text To DiVA

Essén, B., Puthoopparambil, S., Mosselmans, L., Salzmann, T.(2018). Improving the health care of pregnant refugee and migrant women and newborn children: Technical guidance. Rapport. To DiVA

Hargreaves, S., Rustage, K., Nellums, L., Powis, J., Milburn, J. et al.(2018). What constitutes an effective and efficient package of services for the prevention, diagnosis, treatment and care of tuberculosis among refugees and migrants in the WHO European Region?: Themed issues on migration and health, VIII. To DiVA

McGarry, O., Hannigan, A., De Almeida, M., Santino, S., Puthoopparambil, S. et al.(2018). What strategies to address communication barriers for refugees and migrants in health care settings have been implemented and evaluated across the WHO European Region? Themed issues on migration and health, IX. To DiVA

O'Doherty, J., Leader, L., O'Regan, A., Dunne, C., Puthoopparambil, S. et al.(2019). Over prescribing of antibiotics for acute respiratory tract infections; a qualitative study to explore Irish general practitioners' perspectives. BMC Family Practice, 20(1) To DiVA Full text

Takahashi, R., Kruja, K., Puthoopparambil, S., Severoni, S.(2019). Refugee and migrant health in the European Region. The Lancet Elsevier To DiVA

Villarroel, N., Hannigan, A., Severoni, S., Puthoopparambil, S., MacFarlane, A.(2019). Migrant health research in the Republic of Ireland: a scoping review. BMC Public Health, 19(1)To DiVA Full text

Pusztai, Z., Zivanov, I., Severoni, S., Puthoopparambil, S., Vuksanovic, H. et al.(2018). Refugee and migrant health –: improving access to health care for people in between.Public Health Panorama, Copenhagen: World Health Organization. 4(2): 220-224 To DiVA Full text

Puthoopparambil, S., Ahlberg, B., Bjerneld, M.(2013). Do higher standards of detention promote well-being?. To DiVA

Puthoopparambil, S., Bjerneld, M.(2016). Detainees, staff and healthcare services in immigration detention centers: A descriptive comparison of detention systems in Sweden and the Benelux countries. Global Health Action, 9 To DiVA Full text

Puthoopparambil, S., Bjerneld, M., Källestål, C.(2015). Quality of life among immigrants in Swedish immigration detention centres: a cross-sectional questionnaire study. Global Health Action, 8 To DiVA Full text

Puthoopparambil, S., Ahlberg, B., Bjerneld, M.(2015). A prison with extra flavours : Experiences of immigrants in Swedish immigration detention centres. International Journal of Migration, Health and Social Care, 11(2): 73-85 To DiVA Full text

Puthoopparambil, S., Ahlberg, B., Bjerneld, M.(2015). "It is a thin line to walk on": challenges of staff working at Swedish immigration detention centres. International Journal of Qualitative Studies on Health and Well-being, 10: 25196 To DiVA Full text

Slutrapport utvärdering av Rädda Barnens vänprojekt i Knivsta 2015-2017