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. 2024 Jun 18;11(6):e2217. doi: 10.1002/nop2.2217

Reading the signs in health visits—Perspectives of adolescents with migration experiences on encounters with school nurses

Emmie Wahlström 1,2,✉, Maria Harder 1,2, Inger K Holmström 2,3, Peter Larm 4, Marie Golsäter 5,6
PMCID: PMC11187908  PMID: 38890791

Abstract

Aim

To explore the experiences of health visits within the school health services from the perspective of adolescents with migration experiences.

Design

A descriptive qualitative study.

Methods

Data were collected using focus groups and semi‐structured individual interviews with adolescents with migration experiences aged 13–17 years old. Analysis was conducted using reflexive thematic analysis.

Results

The results described adolescents reading the signs in the guided interaction between them and the school nurses. Reading the signs illustrated the adolescents' continuous interpretation of the interaction with the school nurse, and their decisions on how to respond throughout the health visit. These interpretations influenced the adolescents' shifting willingness to talk about their health and how they adapted to the space of participation provided by the school nurse. The interpretation also influenced their experiences of health visits as focusing on their health without making them feel singled out.

Conclusion

Although individual considerations might be warranted in health visits with adolescents with migration experiences, the results indicate that similarities in intrapersonal communication in various encounters between adolescents and health professionals might be greater than any differences. Healthcare encounters with adolescents with migration experiences might thus need to be conducted with an awareness that adolescents read the signs in the guided interaction and that similarities in this interaction are greater than any differences.

Keywords: adolescents, health visits, migration, nursing, school, school health services

1. INTRODUCTION

There is a growing body of research highlighting the importance of promoting adolescents' participation in healthcare. By involving adolescents in healthcare, their confidence and self‐efficacy increases (Davison et al., 2021) and they become actors in constructing the healthcare situation, along with the healthcare professionals (Cahill et al., 2020; Davison et al., 2021; Spencer et al., 2019). Adolescents also want to be involved in decisions regarding their own health, to be treated as equal partners in dialogues about their health and they want to feel respected (Cahill et al., 2020). If their input and preferences are not acknowledged, the adolescents tend to feel disengaged and rejected (Davison et al., 2021). Similar preferences are also valid for adolescents visiting the school nurse during health visits.

2. BACKGROUND

To participate in a health visit, adolescents need to be informed about the purpose of the visit and what a school nurse can assist with (Forkuo‐Minka et al., 2018). The adolescents also want to be invited to participate through the school nurse actively listening, creating a pleasant caring atmosphere, providing encouragement, and respecting the child's rights (Rytkönen et al., 2017). Such actions contribute to adolescents trusting that the nurses will respect their confidentiality (Forkuo‐Minka et al., 2018; Rytkönen et al., 2017) and will assist them in expressing their own view (Rytkönen et al., 2017). To be involved and included in a caring relationship is also important for the adolescents in order for them to be able to disclose more private issues (Cahill et al., 2020). Yet for the minority population of adolescents who have migrated or whose parents have migrated from one country to another, that is, adolescents who have migration experiences, their participation in health visits with the school nurse has been sparsely studied.

Adolescents with migration experiences are a heterogeneous group in terms of languages spoken, nationalities, ethnicities, traditions, and so forth, yet they constitute a growing proportion of children due to conflict, humanitarian, and climate‐related conditions and disasters (World Health Organization, 2022). In Sweden, children with migration experiences constitute about 26 percent of the total population of adolescents (i.e. 10–19 years old; SCB, 2022). Previous research describes encounters between healthcare professionals and school‐aged children with migration experiences as including challenges hampering the interaction (Johnson et al., 2017). School‐aged children describe the encounters as being hampered by a lack of trust in the healthcare services, as well as their sometimes‐limited language proficiency (Curtis et al., 2018). School nurses encountering unaccompanied refugee children describe the encounters as being hampered by their lack of knowledge about trauma‐informed care and intercultural nursing and highlight a need of school nurses having self‐awareness (Musliu et al., 2019). In addition, research shows how school nurses adjust their approach in encounters with children with migration experiences (Wahlström et al., 2021), but research from the children's perspective is lacking. Overall, research on healthcare encounters from the perspective of children with migration experiences is scarce (Curtis et al., 2018; Spencer et al., 2019). Still, research highlights the importance of children being given the opportunity to share their own perspectives on health as these perspectives might not be the same as those of the majority population (Spencer et al., 2019). To manage the mentioned challenges, the knowledge regarding how encounters with the school nurse are experienced by adolescents with migration experiences needs to be increased. Such knowledge could provide insights into issues that are particularly important for the adolescents' health and the promotion of their participation in these visits. In addition, such knowledge might also be useful when developing the school nurses' clinical praxis and the school health services (Forkuo‐Minka et al., 2018; Spencer et al., 2019).

3. THE STUDY

3.1. Aim

The aim of the study was to explore the experiences of health visits within school health services from the perspective of adolescents with migration experiences.

4. METHODS

4.1. Design

A descriptive qualitative study was conducted to explore experiences of health visits within the school health services from the perspective of adolescents with migration experiences, as their perspective is sparsely included in previous research (Curtis et al., 2018; Spencer et al., 2019). Data were collected through focus groups and individual interviews with the adolescents.

4.2. Setting

The Swedish school health services are assigned to monitor risks for ill health as well as to promote health and development for all children, 6–19 years of age (Socialstyrelsen and Skolverket, 2016). To do so, all children attending school are invited to “health visits” conducted by school nurses at the ages of 6, 10, 13, 14, and 16 years old. These reoccurring health visits are free of charge and consist of a scheduled encounter between a child and a school nurse focusing on the child's health and development. During a health visit, the school nurse conducts physical assessments of the child's height, weight, vision, hearing, and the spine as well as a health dialogue about the child's health, living conditions, and development towards an independent life. This study explored the experiences of health visits from the perspective of adolescents with migration experiences in lower (ages 12–16 years old) and upper secondary schools (ages 16–19 years old) in two urban cities and one rural village in the Southern part of Sweden.

4.3. Participants and recruitment

To inform adolescents and invite adolescents to participate in the study, school nurses at schools in two regions in Sweden were engaged in the recruitment process. The school nurses aided the researchers in recruiting adolescents and providing the interested adolescents with information on when and where the focus groups would take place. The school nurses worked at lower (ages 12–16 years old) and upper secondary schools (ages 16–19 years old) located in two urban cities and one rural village. The recruitment process was guided by these school nurses' ordinary schedule of conducting health visits, as conducting focus groups and interviews recently after a health visit would facilitate the adolescents' reflections about the health visits. Information about the study was provided by the school nurses to adolescents aged 13–17 years old who had either been born abroad or had two parents both born abroad (i.e. had migration experiences) and were able to communicate in Swedish without an interpreter. This information to the adolescents as well as their caregivers was provided along with the invitation to the health visit, and the school nurses followed‐up on provided information at the health visit. As soon as four to six adolescents of the same gender had shown an interest in participating, written informed consent of participation was sought from adolescents and caregivers, and a focus group was booked.

Recruitment of adolescents started in October 2019 and by February 2020, three focus groups had been conducted. As the first wave of the COVID‐19 pandemic hit Sweden in March 2020, the health visits were temporarily put on hold thus affecting recruitment of adolescents. Recruitment of adolescents was resumed in the autumn of 2020 and continued until March 2021. During this recruitment period, the recruitment was also supplemented by provision of information about the study and recruitment of adolescents in a leisure time setting (through a sports club). The researchers also distributed a brief video recording of information about the study to the school nurses for posting on the schools' online learning platforms. In total, 17 adolescents chose to participate in the study and provided their written and oral informed consent for doing so. The caregivers of the adolescents were provided with information about the study, and no caregivers objected to their children participating in the study. The group of adolescents consisted of nine adolescents attending lower secondary school and eight attending upper secondary school. All adolescents were aged between 13 and 17 years old and had either been born abroad or had two parents both born abroad (i.e. had migration experiences). They were also able to communicate in Swedish without an interpreter. Four were males and 13 were females.

4.4. Data collection

Data were collected using semi‐structured focus groups and semi‐structured individual interviews with the adolescents. A combination of focus groups and semi‐structured interviews was used to facilitate data collection during the periods of COVID‐19 pandemic when restrictions prohibited encounters in groups. The composition of adolescents in the focus groups was guided by gender, as previous research shows that conversation is facilitated if adolescents of the same gender participate in the same group (Golsäter, 2012). The questions used in the focus group discussion and interviews focused on the adolescents' experiences of participating in health visits, how they would like school nurses to promote their participation in health visits as well as what topics school nurses should address when encountering children and adolescents with migration experiences in health visits. Examples of questions were as follows: how is it to do a health visit at the school nurse's office, what is important for you to be able to actively take part in the health visit, and what do you think is important for school nurses to ask about when talking to children with migration experiences? Questions were adjusted to age and maturity as well as language used among adolescents (Gibson, 2012) and were pilot‐tested with two adolescents with migration experiences aged between 13 and 17 years of age. Pilot testing resulted in minor adjustments to the wording of the questions.

In total, four focus groups and six individual interviews were conducted by the researchers. Focus groups were conducted at school during school hours with two to four adolescents participating in each focus group. Each focus group was conducted by one moderator (EW), who provided guidance to the focus group, with one assistant (MG) taking notes and summarizing the content. For the individual interviews, the adolescents chose where the interview would take place and whether it was to be conducted in person (n = 1), over the phone (n = 1) or via a videoconference call (n = 4). The individual interviews were all conducted by the first author (EW). Focus groups and interviews were audio‐recorded and transcribed verbatim by EW.

4.5. Data analysis

Data were analysed using reflexive thematic analysis (Braun & Clarke, 2022). Using reflexive thematic analysis encourages the visibility of the researcher as a creator of knowledge and highlights the process of actively working with data through coding and creating themes. The creation of themes is thus understood as a creative process that constructs interpretative stories about the data. The analysis in this study has mainly been conducted by EW and MG. Initially, all transcripts were read through to get familiarized with the data. General ideas and analytical observations were written down to be returned to in later phases of the analysis process. EW and MG discussed and compared notes after familiarization to establish a shared understanding which would facilitate the upcoming interpretative work. Next, data segments in all data were marked, selected, and discussed between EW and MG. Initial codes were formulated for each segment based on both semantic and latent contents in the segment. The initial codes were reviewed and revised to make sure that they contained variation but focused on the same aspects of the data. Working with coding and revision of codes also initiated reflection about what main ideas of the interpretation of data generated. These main ideas were used as preliminary themes that were reviewed against codes and data. Throughout this process, the themes were shaped by the evolving interpretations made from the adolescents' experiences and the understanding of the health visit that EW and MG had. An example of the analysis process from data to themes is provided in Table 1. The final themes were discussed among the authors of the manuscript, and negotiated consensus on interpretation was reached.

TABLE 1.

Example of data analysis.

Interview Data extract Preliminary codes Codes Subtheme Theme
5 Take everything they say seriously. I think this is important. Because sometimes… It is something important to me, but when I go to her and she thinks—this is not so important ‐then I feel like she doesn't care about it. She might not like it, but it is important to me… because this thing makes me feel bad…

Feeling like you get the help you need

Show that the student's concerns are taken seriously

 To be taken seriously Willingness is influenced by SN's actions A shifting willingness to talk about my health
4 When I talk about my problems, I don't want her to make a face or anything showing like pity, like—oh that is a shame or like that… […] because that makes me feel like I have huge problems, like unsolvable and then you are like ashamed because of it, well maybe not ashamed, but you feel like very lonely. And for me that is important, that she tell you that you are not alone and that many others experience the same thing.

SN's actions can make problems feel bigger or smaller

Want to be and feel like everyone else (not be alone/different)

 Do not want to feel different from others Balancing between the group and the individual adolescent Focusing on my health without feeling singled out
1 Yes… you want to feel like… I want to participate in this, I want to make a difference, I want to decide too. It is me this is all about. Participating is important when the conversation focuses on me Being able to control the conversation Wanting to be in control I adapt to the space of participation
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4.6. Ethical considerations

The study was approved by the Regional Ethical Committee in Uppsala, Sweden (DNR: 2016/560; 2019‐02113) and the Ethical review agency in Sweden (DNR: 2016/560; 2020‐02532). All written information provided to the adolescents describing the study was adjusted to suit their age. If the adolescents had any questions about the study, they were invited to contact the research group directly or ask the school nurse for more information. Before initiating the focus group and interview, the adolescents were informed about the study by the moderator or interviewer and asked if they had any questions regarding this information or the study. All adolescents were also asked to confirm if they were willing to participate and to provide their written informed consent. Information was also provided to the parents of all adolescents and was adjusted to suit the varied Swedish language skills that parents of adolescents with migration experiences might have. Consent from caregivers was sought by asking them to contact the school nurse, moderator, or interviewer if they did not agree to their adolescent taking part in the study. All adolescents who participated in a focus group were asked to agree on ground rules in order to ensure the confidentiality of the participants. To further ensure confidentiality, details that could be used to easily identify individuals were not included in the transcriptions of the audio recordings, the results of analysed data are presented at group level and quotations are selected carefully to avoid the possibility of identification.

5. FINDINGS

The analysis resulted in three themes, see Figure 1, describing the adolescents' experiences of health visits: A shifting willingness to talk about my health, I adapt to the space of participation, and Focusing on my health without being singled out. In addition, the analysis produced an overarching theme highlighting a shared concept between all three themes: Reading the signs in guided interaction. In the presentation of these results, pseudonyms of the participating adolescents are used.

FIGURE 1.

FIGURE 1

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Illustration of overarching theme and themes.

5.1. Reading the signs in guided interaction

The overarching theme described the adolescents' experiences of reading the signs in guided interaction that is embedded in the structure of health visits. Reading the signs in guided interaction captured the continuous process of adolescents' interpretations and decisions made based on these interpretations in the interaction with the school nurse. The reading of signs included the adolescents' interpretations of the school nurses' verbal and non‐verbal communication that influenced the adolescents shifting willingness to talk about their health. How the adolescents read the sign also included how the school nurses provided space for the adolescents' initiatives, communication, and participation, which created space for the adolescents' participation. It also included the adolescents' decisions on how to respond according to the interpretations made, forming a continuous process of interpretations and responses throughout the health visit influencing their willingness to talk, how they adapted to the space of participation and if they felt singled out or in focus. This process contributed to the adolescents considering themselves as both active participants and passive followers of instructions in the health visit. Their active participation was illustrated by them engaging in the dialogue and through their continuous assessments of the school nurses' actions and decisions on how to act. The adolescents' feelings of being seen as individuals and of being provided with space for sharing thoughts were experienced as contributing to active participation. Still, they also described aspects of loyalty and adherence to the school nurses' instructions based on the school nurses' position of being in charge of the health visit. This position highlighted the school nurses' power when guiding the content and process of the health visits, that is, guiding the interaction. Depending on how the adolescents interpreted the school nurses' use of this position of power when guiding the interaction, the adolescents could shift between feeling safe and wanting to talk about their health to feeling insecure, interrogated, singled out, and refraining from sharing thoughts regarding issues that influence their health.

5.1.1. A shifting willingness to talk about my health

The adolescents' descriptions of participating in health visits highlighted the trust that is developed between school nurses and adolescents and that this might vary throughout the health visit. This varying trust conditioned the adolescents' willingness to share and talk about their health and issues they sound difficult or sensitive: “… the children should be able to trust a person in order to dare to talk and tell this person what you feel, how you are. So, you've got to trust first” (Leyla).

The trust was shaped by the expectations the adolescents had based on previous experiences of school nurses, as discussed in focus group 1:

Ali: Her, that you have met before. You already know that she is nice, whether you can trust her, because of what you have told her before […] Because she has helped you, helped you solve things. So, by then it feels like I can just show up and tell her what I know and what I want to tell her and not feel like it is embarrassing or anything. I can tell her how I feel.

Noah: no prejudice.

Ali: But if it is someone new, then I don't know exactly if I can trust them or if they are nice. So I've got to start from the other way…

Noah: getting to know her […] They have to get my attention…

Ali: Yes, get my… that I can trust her.

In these expectations, the adolescents included both the previous experiences of the school nurse at their school as influential for upcoming encounters (as shown by the citation from focus group 1) and experiences of previous school nurses they had encountered. The adolescents also reflected on past experiences of healthcare professionals in general being influential in the health visit, especially for children and adolescents who had migrated under harsh conditions; “Well, some might have left places where… there was war and such. And might not have had a very good experience when it comes to doctors, nurses and so on. [..] Maybe even sees it like a negative thing” (Fatima).

All these expectations and experiences shaped the adolescents' starting point of the health visit, yet when the health visit had begun the adolescents' willingness to participate and share their stories was described as influenced by the interaction between the school nurse and the adolescent. The adolescents described how they interpreted the school nurses' actions and the way the school nurse responded to their actions, as highlighted by these adolescents in focus group 2:

Zeinab: You can see it, when someone cares and when they don't care. Because…

Mia: They listen ‘till you've finished. […].

Zeinab: and don't raise their voice or anything.

Moderator: … so patiently listening.

Zeinab: and the tone of voice as well.

When adolescents found that the school nurses were interested, caring, and neutral, the adolescents' trust in the school nurse and their willingness to talk about health increased. Yet when the opposite occurred the adolescents lost trust and interest in sharing their thoughts: “I still felt like she weren't really engaged, for real. So that made me back off and I did not want to talk to her” (Farah). The adolescents back off by saying what they think is expected of them and trying to hurry the visit along. The shifting willingness to talk with the school nurse is related to the adolescents' fear of misinterpretation by the school nurse and of unwanted consequences of sharing thoughts. The confidentiality and secrecy of the school nursing profession were acknowledged as a condition of the adolescents' willingness to share their thoughts on health. Yet the adolescents' awareness of the boundaries of secrecy allowing school nurses to act regardless of the adolescents' consent was also described as restricting their willingness to share, as described by the adolescents in focus group 5: “Mariam: you might not trust the school nurse even if she says she has the professional secrecy. You might think she will tell (Maria: exactly) a teacher or a parent or so on. Like you are not a hundred percent (Maria: sure she won't tell) […]. Mariam: Then you won't tell everything about how you feel […], you hide stuff”.

5.1.2. I adapt to the space of participation

The theme I adapt to the space of participation illustrates the adolescents' experiences of the space for participation being conditioned by the school nurses' planning and experience of how to conduct a health visit. This conditioning was multifaceted. The adolescents relied on the school nurses' plan when guiding the health visits and expressed reassurance and safety in knowing what was going to happen during the health visit, yet they also wanted to decide on the content and process of the health visit. The reassurance and safety were described as dependent on a combination of how the school nurses guided the health visits based on their plan, and the adolescents' trust in the school nursing profession and in the competence of the school nurse: “When you enter, she says please sit down and asks how you've been during the last couple of days, what school is like. […] Then she tells you what is going to happen during this visit and asks if you are afraid or anything. Then the questions start. She always starts with the easy questions, then it gets tougher and tougher. […] And she says you don't have to answer if you don't want to. It is only for sake of your health. And then she talks about professional secrecy and how everything stays between me and her, so that is a safe space” (Ali). Still, the combination of the school nurses' plan and guidance, and the adolescents' trust also contributed to the adolescents complying with the school nurses' information, instructions, and guidance: “So she like, she told me that I should sit down. So I sat down. And then she started asking me questions. So I just started answering” (Leyla). At the same time, the adolescents' compliance and trust in the plan, guidance, and professional competence of school nurses was also accompanied by their wishes and expectations of being involved in the health visit: “you want to feel like… I want to participate, I want to make a difference. I want to decide too. It is me it's all about” (Hamza). The adolescents wanted to be able to prepare for the health visits, decide what would be discussed and be involved in decisions regarding actions to be taken based on the results of the health visit: “it is always good to discuss with an adolescent, if you are a school nurse. […] And that you could kind of present the adolescent with different options of what to do. Not one or two options but maybe several options” (Sofia).

The adolescents also expressed an awareness of the school nurses' position as the facilitator of their participation in the health visit. This position was illustrated in examples of how school nurses invited them to share their thoughts and allowed their descriptions and questions about health to guide the content in the health visit: “She asked me if I had like any questions that I wanted to ask her. […] She was just like, you can tell me if you'd like to ask any question, even questions you might be afraid to ask. You can ask me now” (Leyla). On the other hand, when the adolescents experienced that such involvement was missing the adolescents described a feeling of being interrogated and fatigue caused by answering questions: “If she is going to sit there and ask me questions about stuff I don't have any problems with right now, well that's just unnecessary” (Elena). The lack of involvement also hindered the adolescents from posing their own questions and resulted in a passivity where the adolescents strictly answered the questions and refrained from engaging in the dialogue.

5.1.3. Focusing on my health without being singled out

The theme Focusing on my health without being singled out described the adolescents' experiences and expectations of the dialogue concerning health and lifestyle in relation to them opening up about their health. The adolescents discussed the dialogues as opportunities for promoting and learning about their health as well as controlling their health status and identifying risks of ill health. In these dialogues, the school nurses' way of communicating about the adolescents' health influenced the adolescents' thinking about their health: “She made me think, in that way I have decided. Because when you get the idea that it is your life and it is about you, then of course […] you want to do what is good for you” (Mia). The adolescents also highlighted the importance of being treated as unique individuals in the dialogues: “It was like she read me and my actions, like she knew who I was even though she did not know me before. If she had told me something that I did not relate to I don't think I would have cared as much” (Fatima). Still, the adolescents also stressed that they wished to feel normal and not feel different from everyone else; otherwise, they might refrain from sharing more about their health: “Because it makes me feel like I have very big problems and that they are almost unsolvable… and that I am kind of embarrassed by it. Well not embarrassed, but […] you feel lonely. And I think it is important that you don't feel lonely and that she says that many people suffer from it” (Farah). The adolescents thus expected the school nurses to balance between encountering them as individuals and using knowledge about the health of adolescents in general to assess their health and relieve any doubts about being different or alone in their situation. The adolescents wanted to be treated equally and did not wish the school nurse to assumptions about them and their health based on them having migration experiences. The adolescents also expected the school nurse to ask them questions about things that might influence their health, such as their family, everyday life, friends, mental health, and growing up between cultures. While discussing these subjects, the school nurses were expected to use questions based on general topics to approach issues that might be considered sensitive: “But she shouldn't ask the questions straight up, no she really shouldn't. […] There are other ways. How is it at home? What would it be like if you got involved with someone…? Are you involved with someone? Questions like that are better” (Mia).

6. DISCUSSION

The results of this study show that adolescents with migration experiences describe their experiences of health visits as Reading the signs in guided interaction. They describe a continuous interpretation of signs in the interaction between themselves and the school nurse which conditions their willingness to share thoughts about their health and their participation in the health visit. These findings are similar to how interpersonal communication between adolescents who have no migration experiences and healthcare professionals within a broad range of healthcare settings is described (Davison et al., 2021; Kim & White, 2018). Interpersonal communication needs to cope with challenges of addressing sensitive aspects of adolescents' lives, create trust and emotional safety to enable open and engaging communication, as well as contribute to the adolescents' sense of inclusion and autonomy. Similarly, previous research also suggests that development of trust in the school nurse is essential in encounters between school nurses and adolescents (Cahill et al., 2020; Forkuo‐Minka et al., 2018; Rytkönen et al., 2017). Thus, the results in this study and previous research highlight several similarities in intrapersonal communication among various adolescents and health professionals in healthcare settings. Although, as a review of adolescents' trust in healthcare professionals showed that consistent distrust was reported among adolescents who had migrated or belonged to a minority ethnicity (Hardin et al., 2021), the importance of developing trust between healthcare professionals and this group of adolescents might be even greater than for other groups of adolescents.

The results might also be understood as relating to another shared point of reference for all adolescents, that is, their psychological and social development. The theme of I adapt to the space of participation could be considered highlighting aspects of the adolescents' developing sense of autonomy (as described by Zimmer‐Gembeck & Collins, 2005). The adolescents acknowledge that their autonomy is restricted in the situation and seem to be content with this, although also expressing a desire to guide the situation themselves. This desire to guide the situation might relate to a growing sense of self and a desire for autonomy. In addition, the theme Focusing on my health without being singled out highlights another developmental aspect of adolescents: their sense of self in relation to fitting in with the norms among peers (Bradford Brown & Klute, 2005). The adolescents highlight that they want the school nurse's assurance about them not being different and that there are others who also experience similar difficulties. Still, the theme also illustrates aspects of a developing autonomy in relation to the adolescents having and taking control over their health through the health visit.

Having and taking control over their health relates to the adolescents' health literacy (Bröder et al., 2020). In the theme Focusing on my health without being singled out, the adolescents describe health visits as a place where adolescents gain health information adapted to their needs, discuss their health with a trusted professional, and gain support in how to promote their health. Health visits, as described by the adolescents, might thereby serve as a context where the development of health literacy is promoted. Similarly, research has suggested that the mere presence of a school nurse at schools working with basic caring, as well as health‐promoting activities, increases adolescents' health literacy (de Buhr et al., 2020). School nurses thereby have a unique position in supporting adolescents' learning about their own health and promoting their health literacy. This position might be strengthened through the conditions of the health visits described by the adolescents, that is, an interaction that facilitates trust between the adolescent and the school nurse as well as the creation of space for the adolescents' participation. Health literacy is strengthened by conditions that balance guidance, protection, and support, and also creates spaces for adolescents' autonomy and independence in decision‐making regarding their own health (Bröder et al., 2020). Similarly, the mentioned conditions are also echoed in the conditions preferred by adolescents when discussing their health (Forkuo‐Minka et al., 2018; Rytkönen et al., 2017). Such conditions include school nurses encouraging adolescents to express their views, respecting the child's rights (Rytkönen et al., 2017) and creating an interaction which contributes to the development of trust between the school nurse and the adolescent (Cahill et al., 2020; Forkuo‐Minka et al., 2018; Rytkönen et al., 2017).

The aforementioned similarities indicate that the adolescents in this study share experiences of participating in health visits with adolescents who have participated in healthcare encounters in other studies. Still, the adolescents participating in this study also highlighted some experiences that might be considered specific for them or related to them having migration experiences. One such reflection raised by the adolescents is the necessity of the school nurse asking questions in a sensitive manner about the adolescents' past life experiences, especially if the adolescents themselves have migrated. Posing questions related to the influence of factors pre‐, during, and post‐migration on adolescents' health is important as these factors influence the adolescent's current and future health (Abubakar et al., 2018). The importance of school nurses' knowledge and tact when talking about health was also raised when asking about relationships and family (highlighted in the quote by Mia on page 16). Relationships with others might be a sensitive topic to address with adolescents, especially if they live in families or communities guided by norms regarding honour control relationships and sexuality. Still, such norms affect adolescents' health as research has shown that restrictions regarding the adolescents' possibilities of choosing a future partner are related to mental health problems (Bengtsson et al., 2021). That the school nurses should ask such questions about family, relationships, and other topics related to health was expected by the adolescents, yet they also highlighted that school nurses should not make assumptions about them, or their health based on any preconceived ideas or prejudice. Such emphasis on school nurses not making assumptions about them and their health might relate to findings indicating that about 15 percent of 12–15‐year‐olds and between 23 and 30 percent of 16–18‐year‐olds who have recently migrated to Sweden report feeling badly treated because of their background (Folkhälsomyndigheten (FHM) [Public health agency of Sweden], 2019). Similarly, other findings report negative racial stereotypes of adolescents being endorsed by adults working with children (Priest et al., 2018). Further research is needed into what the adolescents imply by highlighting the importance of not making assumptions.

In summary, the results show both experiences shared within the overall population of adolescents, and nuances of these experiences that might be unique for adolescents with migration experiences participating in health visits. The similarities in adolescents' experiences also stress the previously highlighted importance of considering that within‐group differences might be larger than any between‐group differences of children (Abubakar et al., 2018).

6.1. Strengths and limitations of the work

The results of this study should be considered in relation to the limitations of the study. The recruitment of participants was stretched over time, partly not only due to the pandemic but also due to the school nurses' difficulties in finding adolescents who were interested in participating. During the pandemic, the school nurses had to make pauses in conducting health visits, which contributed to the recruitment of participants also being paused, thus prolonging the recruitment period. Previous research has illustrated challenges when recruiting adolescents, especially within minority populations (Shaw, 2018). However, the difficulties in inspiring interest in adolescents to participate in the study might also illustrate the adolescents' autonomy in choosing whether to participate or not once information about the study had been provided. The data gathered through the focus groups and interviews were rich in describing various experiences, and the last conducted interviews contributed with only a few new aspects in relation to previously collected data. The variation in the adolescents' ages, gender, schools they attended as well as whether they had migrated or had parents who had migrated might be considered both a limitation and a strength. The variation within this group of adolescents could contribute to variation in experiences, yet the results might only be transferrable to adolescents in similar contexts and with similar characteristics. Some of the focus groups were only attended by two adolescents, although four to six adolescents had signed up for the focus group. Still, when conducting focus groups with children or adolescents, a smaller number of participants are sought as this facilitates their communication (Gibson, 2012). Another limitation of the study is that the interpretations of data are shaped by the experiences and perspectives of EW and MG. As neither EW nor MG have migrated or have parents who have migrated, this might have contributed to interpretations being made in different ways than if a researcher with migration experiences had conducted this research.

6.2. Practical implications and recommendations for further research

The results of the study have several implications for the practice of school nurses and other professionals working with individual encounters to promote adolescents' health. The reading of signs in guided interaction highlights the shared aspects of interpretation in intrapersonal communication among adolescents in various studies, which might imply that previous knowledge on intrapersonal communication could be applied in health visits with children with migration experiences. The results also highlight the importance of developing trust in these encounters, which is also confirmed by previous research (Cahill et al., 2020; Forkuo‐Minka et al., 2018; Rytkönen et al., 2017). However, especially Focusing on my health without being singled out highlights issues that might be considered specific to promoting the health of adolescents with migration experiences. This illustrates that school nurses and other professionals might need to use a combination of approaches in encounters with these adolescents that include a consideration of both adolescent health in general and the individual adolescent's needs, wishes, and experiences. Similarly, Wahlström et al. (2021) have shown that school nurses describe using a combination of approaches when promoting the participation of children of foreign origin in health visits. This combination included adjustments made based on both the children's language proficiency and cultural or national background and the needs and wishes of the individual child as well as doing the same for all children. Still, how this interaction is enacted between school nurses and adolescents might need further research using observational methods. Further research might also focus on the aspects of equity in the encounters by looking into what the adolescents imply by highlighting the importance of not making assumptions.

7. CONCLUSION

The experiences of health visits among adolescents with migration experiences were described as reading the signs in the guided interaction of the health visit. The adolescents' interpretations of the signs between themselves and the school nurses in the interaction influenced the adolescents' willingness to share, participation, and feeling of being in focus. Although reading the signs in the guided interaction describes the adolescents' experiences of health visits, these experiences might also reflect universal aspects of intrapersonal communication among adolescents and health professionals. The results could thus be understood as illustrating both similarities in experiences of health visits that might be shared among adolescents in general, and aspects that might have relevance when encountering adolescents who have migrated or whose parents have migrated.

AUTHORS' CONTRIBUTION

EW: conceptualization (lead), methodology (equal), investigation (equal); formal analysis (equal); writing – original draft (lead); writing – review and editing (equal). MH: conceptualization (supporting), methodology (supporting), writing – review and editing (equal). IKH: conceptualization (supporting), methodology (supporting), writing – review and editing (equal). PL: conceptualization (supporting), methodology (supporting), writing – review and editing (equal). MG: conceptualization (supporting), methodology (equal), investigation (equal); formal analysis (equal); writing – review and editing (equal); supervision.

FUNDING INFORMATION

This research received no specific grant from any funding agency in the public, commercial, or not‐for‐profit sectors. The research was conducted as part of the employment at the School of Health, Care and Social Welfare at Mälardalen University.

CONFLICT OF INTEREST STATEMENT

The authors declare that there are no conflicts of interest.

ETHICS STATEMENT

The study was approved by the Regional Ethical Committee in Uppsala, Sweden (DNR: 2016/560; 2019–02113) and the Ethical review agency in Sweden (DNR: 2016/560; 2020–02532).

ACKNOWLEDGEMENTS

We thank the adolescents who have shared their experiences with us and the school nurses who helped in informing adolescents about the study.

Wahlström, E. , Harder, M. , Holmström, I. K. , Larm, P. , & Golsäter, M. (2024). Reading the signs in health visits—Perspectives of adolescents with migration experiences on encounters with school nurses. Nursing Open, 11, e2217. 10.1002/nop2.2217

DATA AVAILABILITY STATEMENT

Data will be available upon reasonable request.

REFERENCES

  1. Abubakar, I. , Aldridge, R. W. , Devakumar, D. , Orcutt, M. , Burns, R. , Barreto, M. L. , Dhavan, P. , Fouad, F. M. , Groce, N. , Guo, Y. , Hargreaves, S. , Knipper, M. , Miranda, J. J. , Madise, N. , Kumar, B. , Mosca, D. , McGovern, T. , Rubenstein, L. , Sammonds, P. , … Zhou, S. (2018). The UCL–Lancet Commission on migration and health: The health of a world on the move. The Lancet (British Edition), 392(10164), 2606–2654. 10.1016/S0140-6736(18)32114-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Bengtsson, D. , Landberg, Å. , & Jernbro, C. (2021). Increased risk of child maltreatment and mental health problems among adolescents with restrictions regarding choice of future partner: Results from a Swedish school‐based survey. Scandinavian Journal of Public Health, 50, 1133–1139. 10.1177/14034948211053138 [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Bradford Brown, B. , & Klute, C. (2005). Friendships, cliques and crowds. In Adams G. R. & Berzonsky M. (Eds.), Blackwell handbook of adolescence, chapter 16 (pp. 330–348). Blackwell Publishing Ltd. 10.1002/9780470756607.ch9 [DOI] [Google Scholar]
  4. Braun, V. , & Clarke, V. (2022). Thematic analysis, a practical guide. Sage Publications. [Google Scholar]
  5. Bröder, J. , Okan, O. , Bauer, U. , Schlupp, S. , & Pinheiro, P. (2020). Advancing perspectives on health literacy in childhood and youth. Health Promotion International, 35(3), 575–585. 10.1093/heapro/daz041 [DOI] [PubMed] [Google Scholar]
  6. Cahill, H. , Wyn, J. , & Borovica, T. (2020). Youth participation informing care in hospital settings. Child and Youth Services, 40(2), 140–157. 10.1080/0145935x.2019.1567323 [DOI] [Google Scholar]
  7. Curtis, P. , Thompson, J. , & Fairbrother, H. (2018). Migrant children within Europe: A systematic review of children's perspectives on their health experiences. Public Health, 158, 71–85. 10.1016/j.puhe.2018.01.038 [DOI] [PubMed] [Google Scholar]
  8. Davison, G. , Kelly, M. A. , Conn, R. , Thompson, A. , & Dornan, Y. (2021). How do children and adolescents experience healthcare professionals? Scoping review and interpretive synthesis. BMJ Open, 11, e054368. 10.1136/bmjopen-2021-054368 [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. de Buhr, E. , Ewers, M. , & Tannen, A. (2020). Potentials of school nursing for strengthening the health literacy of children, parents and teachers. International Journal of Environmental Research and Public Health, 17(7), 2577. 10.3390/ijerph17072577 [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Folkhälsomyndigheten (FHM) [Public health agency of Sweden] (2019). Hur mår nyanlända barn i Sverige? Resultat från en kartläggning av hälsa, livskvalitet och levnadsförhållanden bland barn från Afghanistan, Irak och Syrien. [How are newly arrived children in Sweden? Results from a survey of health quality of life, living conditions among children from Afghanistan, Iraq and Syria]. Folkhälsomyndigheten. https://www.folkhalsomyndigheten.se/publicerat‐material/publikationsarkiv/h/hur‐mar‐nyanlanda‐barn‐‐i‐sverige/ [Accessed 16 June, 2019]. [Google Scholar]
  11. Forkuo‐Minka, A. , Kennedy, C. , & Work, F. (2018). Young people's expectations regarding their participation in the school nursing service. British Journal of School Nursing, 13(6), 278–281. 10.12968/bjsn.2018.13.6.278 [DOI] [Google Scholar]
  12. Gibson, J. E. (2012). Interviews and focus groups with children: Methods that match children's developing competencies. Journal of Family Theory and Review, 4, 148–159. 10.1111/j.1756-2589.2012.00119.x [DOI] [Google Scholar]
  13. Golsäter, M. (2012). Hälsosamtal som metod att främja barns och ungdomars hälsa – En utmanande uppgift . [Health dialogues as a method of promoting children's and adolescents' health—A challenging assignment; doctorate thesis]. Jönköping: Hälsohögskolan, Högskolan i Jönköping.
  14. Hardin, H. K. , Bender, A. E. , Hermann, C. P. , & Speck, B. J. (2021). An integrative review of adolescent trust in the healthcare provider relationship. Journal of Advanced Nursing, 77, 1645–1655. 10.1111/jan.14674 [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Johnson, J. L. , Beard, J. , & Evans, D. (2017). Caring for refugee youth in the school setting. NASN School Nurse, 32(2), 122–128. 10.1177/1942602X16672310 [DOI] [PubMed] [Google Scholar]
  16. Kim, B. , & White, K. (2018). How can health professionals enhance interpersonal communication with adolescents and young adults to improve health care outcomes?: Systematic literature review. International Journal of Adolescence and Youth, 23(2), 198–218. 10.1080/02673843.2017.1330696 [DOI] [Google Scholar]
  17. Musliu, E. , Vasic, S. , Clausson, E. K. , & Garmy, P. (2019). School nurses' experiences working with unaccompanied refugee children and adolescents: A qualitative study. SAGE Open Nursing, 5, 1–8. 10.1177/2377960819843713 [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Priest, N. , Slopen, N. , Woolford, S. , Philip, J. T. , Singer, D. , Kauffman, A. D. , Mosely, K. , Davis, M. , Ransome, Y. , & Williams, D. (2018). Stereotyping across intersections of race and age: Racial stereotyping among White adults working with children. PLoS One, 13(9), e0201696. 10.1371/journal.pone.0201696 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Rytkönen, M. M. , Kaunisto, M. A. , & Pietilä, A.‐M. K. (2017). How do primary healthcare and social services enable young people's participation? Health Education Journal, 76(6), 730–740. 10.1177/0017896917713234 [DOI] [Google Scholar]
  20. SCB . (2022). Barn och unga med svensk och utländsk bakgrund, antal efter kön, ålder, utländsk/svensk bakgrund och år [Children and adolescents of Swedish and foreign origin, count by sex, age, foreign/Swedish origin and year]. http://www.statistikdatabasen.scb.se/pxweb/sv/ssd/START__LE__LE0102__LE0102A/LE0102T15/table/tableViewLayout1/ [Accessed 21 April, 2022].
  21. Shaw, J. E. (2018). Desiring self‐determination in research and beyond: Parental consent requirements and situated ethics for migrant young people living amid changing family dynamics. Children and Society, 32, 433–443. 10.1111/chso.12277 [DOI] [Google Scholar]
  22. Socialstyrelsen and Skolverket . (2016). Vägledning för elevhälsan [guidance of the school health services] (3rd ed.). Socialstyrelsen. [Google Scholar]
  23. Spencer, G. , Smith, M. , Thompson, J. , Fairbrother, H. , Hoare, K. , Fouché, C. , & Curtis, P. (2019). Health experiences of children and young people who migrate—Opportunities for health education. Health Education Journal, 78(1), 96–107. 10.1177/0017896918786767 [DOI] [Google Scholar]
  24. Wahlström, E. , Golsäter, M. , Granlund, M. , Holmström, I. K. , Larm, P. , & Harder, M. (2021). Adjusting and doing the same: School nurses' descriptions of promoting participation in health visits with children of foreign origin. BMC Public Health, 21(1), 111. 10.1186/s12889-020-10144-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. World Health Organization . (2022). World report on the health of refugees and migrants. https://www.who.int/publications/i/item/9789240054462
  26. Zimmer‐Gembeck, M. J. , & Collins, W. A. (2005). Autonomy development during adolescence. In Adams G. R. & Berzonsky M. (Eds.), Blackwell handbook of adolescence, chapter 9 (pp. 175–204). Blackwell Publishing Ltd. 10.1002/9780470756607.ch16 [DOI] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Data will be available upon reasonable request.

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