How young migrants perceive school health education in Sweden

Abstract

The aim of this paper is to provide insights into how young people who have been forced to migrate perceive school health education. Eighteen individuals aged 15–19 years (10 females, 8 males, average age 16.9 years) took part in either focus group interviews (n = 7) or individual interviews (n = 1). Participants were first presented with short scenarios concerning health education and were invited to use these scenarios as starting points to discuss their own experiences of health education. Participants were then presented with a collection of photographs that portrayed people displaying broad dimensions of health. Participants were asked to discuss the significance of the health dimensions in their lives, and describe how these dimensions were covered in school health education. Our findings suggest three broad perceptions of health education content: a moderately enthusiastic perception, a disengaged perception, and a marginalized perception. These findings: raise questions about whether the provision of health education matches the needs of young migrants, point to cultural differences in the way health topics are understood, and suggest that school health education might influence how migrants interact with health service providers.

Introduction

Young people who have experienced forced migration often suffer from a range of health problems [1, 2]. Researchers have paid special attention to psychological and emotional health issues [3], but reports suggest that this group may also be over-represented in infectious and chronic disease statistics [4, 5]. Possibly exacerbating the situation, young migrants appear to be reluctant to seek health advice from medical services [6]. Within this context, school health education—often provided as part of compulsory schooling in resettlement countries, with its focus on topics such as mental health and wellbeing, identity and self-worth, managing change, and building resilience [7]—would appear to be a valuable site for health promotion. Yet little is known about how young migrants encounter health education in schools. The aim of this paper is to provide insights into how young people who have been forced to migrate perceive school health education. To achieve this aim, we present findings from an investigation in which 15- to 19-year-olds described their experiences of health education in Swedish schools.

Migrants, young migrants, and health

Although humans have migrated throughout history, recent geopolitical events have led people to move in unprecedented numbers and in challenging circumstances. A burgeoning body of literature has documented the health challenges migrants face [4, 5, 8], and according to O’Connor [9], migrant health is one of the most pressing public health issues of the century. Scholars have recognized that health challenges result from events that occur before and during migration, as well as after resettlement [1]. Most research concentrates on problems experienced after resettlement, including sleep disorders, mental health problems such as depression and anxiety, and musculoskeletal complaints [10–12]. In line with a focus on resettlement and integration, health researchers have shown considerable interest in how migrants access healthcare [13, 14].

In migrant health scholarship, it has often been assumed that young people face similar problems to their adult counterparts [2]. Many studies of young migrants’ health are based on questions that have been addressed in adult populations [4] and result in similar conclusions. Research on young migrants suggests, for example, that adolescents are reluctant to seek professional help for psychosocial problems [15], and that distrust of authority, and lack of linguistic and cultural knowledge prevent young migrants from accessing health information. Mirroring trends in adult-focused research, a relatively small number of studies have examined factors specifically associated with well-being, as opposed to illness and disease. Nonetheless, findings from Correa-Velez et al. [16] indicated that a longer period of schooling prior to arrival in a resettlement country, greater self-esteem, a supportive social environment, and strong ethnic identity were positively associated with wellbeing. Edge and colleagues [17] maintained that sense of belonging, positive self-identity, emotional well-being, and sense of agency are critical to young migrants’ health.

Despite similar lines of enquiry in adult migrant research and young migrant research, scholars have proposed that the two groups are not directly comparable [2], and that current research approaches to young migrants’ health have conceptual limitations [18]. Curtis and colleagues [3] claim that extant studies have relied on biomedical frameworks that often miss migrant children’s own understandings of health and illness (see also [18]). Spencer et al. [2] too, propose that researchers have often directed their attention to the adverse outcomes of migration and perpetuated popular understandings of the migrant child as especially vulnerable through a deficit orientation.

The current investigation seeks to circumvent identified limitations in two ways. First, we examine young migrants as a group with characteristics distinct from adults. We are specifically interested in young migrants as school students because schools: have been shown to play a protective role in students’ health [19], assume significant responsibility for the wellbeing of students in many nations [20], and provide official, explicit instruction about health in the form of health education lessons [21]. Furthermore, while studies of health education and migration exist [22, 23], how health education in schools is encountered by young migrants has received little attention [24]. Second, our research positions young migrants as agents who make decisions and judgements about health knowledge. This positioning is reflected in our aim—to provide insights into how young migrants perceive health education—and in our methodological approach, which is described in the next section.

Methods

The perspective adopted in the current investigation is interpretive in nature [25] and we have closely examined young people’s experiences of health education in schools. Close examination has involved an attempt to explain the perceptions that young migrants develop of health education and identify both patterns across the group of participants and unique characteristics that distinguish the individuals.

Participants and recruitment

Participants in this investigation were 18 people aged 15–19 years (10 females, 8 males, average age 16.9 years—for summary of population characteristics, see Table I), who were attending one of three upper secondary schools in Sweden at the time of the investigation. The participants came from 14 countries: Afghanistan, Bosnia, Burma, The Democratic Republic of Congo, Eritrea, Ethiopia, Gambia, Iran, Kenya, Nigeria, Pakistan, Somalia, Syria, and the Ukraine. They had migrated under diverse conditions: some fled extremely risky environments, while others sought out better life chances. The participants had been in Sweden for between 4 months and 8 years (average length of time: 37 months). Several participants had received 11–12 years of schooling before migrating to Sweden, several had received no schooling at all, the others fell somewhere in between. Some had received refugee status since arriving in Sweden, some were seeking refugee status, and as experienced in other research [3], some were unsure of their status. We recognize that aggregating these categories conceals individual differences [8]. To counter the loss of contextual understanding that comes with aggregation, we provide participants’ gender, country of origin, age, and length of time spent in Sweden with the participants’ data later in the paper.

Table I.

Characteristics of the study population

N	Sex	Age	Country of origin	Number of years in Sweden	Number of years schooling in home country
P1	F	17	Ukraine	1.5	9
P2	F	17	Eritrea	5	5
P3	M	17	Iran	0.3	11
P4	M	19	Afghanistan	2	11
P5	M	17	Gambia	1.5	0
P6	F	17	Pakistan	1	12
P7	F	17	Lithuania	0.7	10
P8	M	15	Kenya	4	7
P9	M	15	Afghanistan	8	2
P10	M	15	Ethiopia	5	0
P11	F	16	Iran	5	5
P12	F	18	Ukraine	1	11
P13	F	18	Burma	4	0
P14	F	17	Bosnia	1	10
P15	F	18	Somalia	5	0
P16	F	17	Nigeria	1	12
P17	M	17	D.R. Congo	3	9
P18	M	18	Syria	6	4

This table summarizes the social and demographic characteristics of the study population.

Recruitment took place via the schools that the young people were attending. Teachers from three schools who had participated in an earlier phase of the project were contacted [26]. The teachers were asked to relay information about the project to students they believed had experienced forced migration, along with an invitation to participate. If the students accepted the invitation, the teachers recommended a time for the researchers to come to the school. The researchers then supplied additional information about the project and distributed consent forms for the students to complete (see below).

Research context: health education in Sweden

School health education occurs in different ways in different countries [21]. In Sweden, health education is provided across four school subjects—science education (biology), social studies, home and consumer studies, and physical education [27]—until the end of grade nine (students aged ∼16 years). In grades 10–12, health education is provided across three subjects as home economics is not offered in these grades. In addition, some schools offer ‘project weeks’ in which specific health topics such as ‘relationships’ are covered intensively across all school subjects. Swedish health educational content is wide-ranging. According to the national curriculum, it includes topics such as movement skills and an interest in being physically active in physical education, lifestyle choices relating to consumers and the environment in home economics, knowledge about democracy and human rights in social sciences, and knowledge about the physical body, lifestyle risks and sex education in the subject science education [26]. The educational content of health education is thus addressed by multiple teachers in Swedish schools and potentially intersects with many aspects of students’ personal and social lives.

Data production

Data were produced through seven focus group interviews and one individual interview held at the participants’ schools. Four focus group interviews were conducted with two participants, one with three participants, and two with four participants. Focus groups were chosen not just for their capacity to stimulate discussion and encourage detailed responses, but for the opportunity they provided for the participants to help one another with language comprehension and expression. The number of participants in each interview was nonetheless influenced by practical factors, namely which students were available at a given time and which students the teachers thought would be willing to talk to one another. In the case of the smaller groups and the individual interview, we were satisfied that students provided detailed responses and that those who needed language help received it, even if these interviews did not meet the technical requirements of focus groups in terms of participant numbers. In the first part of the interviews, a vignette technique was employed [28]. The participants were presented with several short scenarios about health and wellbeing concepts being addressed in school and were invited to use these examples as starting points to discuss experiences in health education (see Appendix). Vignettes have been shown to be particularly useful conversational props when the interview topic is abstract or in need of contextualization [29]. In our case, embedding concepts such as sexuality and consent within vignettes was used to broach potentially contentious dimensions of health education by showing how the concepts could become problematic for the characters in the vignettes. During discussions, the interviewer used a semi-structured interviewing approach [30], asking the participants to elaborate on and explain their responses.

In the second part of the interviews, a photo elicitation technique was employed [31], where the participants were presented with a collection of photographs that contained people displaying broad dimensions of health. These dimensions were developed from literature that examined health conceptions in countries from which people have recently been forced to immigrate such as Afghanistan [32] and Somalia [33]. The dimensions included: (i) sense of community and family, (ii) spirituality, (iii) Western medicine, (iv) nutrition, food, and meal culture, (v) natural spaces and urban spaces, (vi) psychological health and stress, and (vii) physical activity and sport. Using photos in interview situations has proven an effective way of connecting the social worlds of the interviewer and the interviewees [34]. In this study, photos helped the students to conceptualize notions of health and wellbeing and created an environment where the participants felt comfortable expressing their perceptions [35]. All interviews were conducted by Caldeborg, who is a Swedish, white, middle class, self-identified woman, and former teacher. Caldeborg has experience of working with young people with migration backgrounds both as researcher and teacher. Interviews were held in a combination of Swedish and English. The participants frequently helped each other to understand questions or express their answers and both interviewer and participants asked for clarification frequently. The interviews lasted between 43 and 65 min.

Analytic approach

The interviews were recorded and transcribed verbatim in a combination of Swedish and English. Analysis of the transcripts was guided by the analytic question: what types of perceptions of health education are evident in the data? Answering the question involved the first author familiarizing himself with the transcripts and copying all extracts that contained descriptions of experiences in health education into a separate Word document. The first author then highlighted extracts in the new document, writing codes that described the extracts in the margins of the document in an open manner. One recurring code was ‘health education is not important’. Recurring codes served as a basis for creating themes representing the participants’ perceptions of health education. For example, the extracts coded ‘not important’, ‘unmemorable’, and ‘health education has little significance’, were placed into a Word document titled ‘Disengaged perception of health education’. Once three preliminary theme documents had been created and the coded transcript extracts had been copied into these documents, the research group followed Goodyear, Kerner, and Quennerstedt’s [36] deliberative strategy to ensure that the extracts matched the theme description. This involved discussing the themes and searching for exceptions or instances in the transcripts that added complexity to the themes. Diversity in the authors’ backgrounds and experiences with respect to gender, ethnicity and to some extent, age ensured different personal perspectives were brought to bear on the findings. At the same time, the fact that all authors are middle class academics could potentially have resulted in bias. When all four authors were satisfied with the contents and labelling of the three theme documents, the first author began writing. During the writing phase, the authors met every 4 weeks for 4 months to discuss draft copies of the manuscript and specifically, whether the findings and interpretations accurately reflected the empirical material. In the final version before submission, interview extracts in Swedish were translated into English by the first and second authors, who using their experience as native English and Swedish speakers, remained as close to the participants’ original meaning as possible.

Ethical considerations

The study was approved by the Swedish Ethical Review Authority (Dnr 2019–06129), safeguarding the requirements of institutional ethics. Concerning procedural ethics, we realize that by asking about personal topics such as nutrition, families, and personal habits, we may have affected the participants in unexpected and unintended ways. We also recognize that our interview format and content might have encouraged specific responses and affected how the participants positioned themselves with respect to the interviewer and their fellow participants during the interviews. The potentially sensitive nature of the topics was explicitly addressed in the introduction to the interviews in most cases resulting in what we felt was open and thoughtful responses. Participants’ anonymity in the publication of findings has been sought through the adoption of pseudonyms and the limited use of identifying material (e.g. school or place names).

Findings

The participants perceived Swedish health education in three general ways: (i) moderately enthusiastically; (ii) in a disengaged manner, and (iii) in a marginalized manner. Importantly, no participant displayed singular perceptions of health education; instead, the participants described multiple perceptions of different topics within health education. Students cannot therefore be grouped by how they perceive health education. Below, we show the complexity involved in their perceptions, include reference to the specific content the participants mentioned, and begin to develop insights into the pedagogical implications of how participants perceive health education. These insights are then extended in the remainder of the paper.

A moderately enthusiastic perception of health education

In many instances, participants expressed tempered enthusiasm towards health education topics. They recollected learning about health topics and often indicated that the knowledge was somewhat interesting and useful. They cited a range of topics that they had covered in different school subjects including religion, environmental pollution, and equality and tolerance, and described lesson content in some detail. Even when some participants noted that in their countries of origin, topics such as menstruation would have been discussed with family members rather than with peers and teachers at school, they suggested that it was good that these topics were raised at school. Several participants recalled a healthy eating model that they had encountered and discussed the value of eating proteins, carbohydrates and fats. They noted that poor nutrition, which they described as diets with high levels of sugar and low amounts of fresh fruits and vegetables, could affect their moods and/or decrease their ability to concentrate.

Some students claimed that health education had provided them with resources to access other health information, which they felt could be valuable in the future. P11’s commentary below is illustrative:

P11: They say that there are places you can go. Like, if you’re depressed, there’s… there’s a wall with all these bits of paper. You can ring and get help there. For example, BRIS [Children’s Rights in Society – an organization that advocates for young people].

Interviewer: Aah, you have, like, an information board?

P11: Yeah, by the counsellor. You can ring there anytime you need to.

(P11, female, Iranian, 16 years old, 5 years in Sweden)

None of the participants mentioned using health services. Still, health education provided a feeling of security by reminding the participants of the services’ availability.

Of the health education topics raised, participants often expressed most enthusiasm for physical activity and sport. Many claimed that being physically active was important for their emotional wellbeing, a point that had frequently been emphasized by their biology and physical education teachers. For many, the benefits of physical activity had also been underscored at the schools in their countries of origin, which meant that doing, and being encouraged to do, physical activity was familiar. One female participant noted, nonetheless, that her opportunities for physical activity would have been curtailed had she not migrated. Her quote can be understood as tacit endorsement for the presence of physical activity on the Swedish school curriculum:

P6: In my country, boys do sports. But not girls. After the fifth grade, it’s not for girls.

Interviewer: Okay. But do they talk about it being good to exercise?

P6: For boys, not for girls. I don’t like it. It’s where I don’t agree. It’s kind of stupid. How is this possible? Like, boys can swim, but girls don’t. Boys can do this, and girls cannot. It’s stupid. Yeah.

(P6, female, Pakistan, 17 years old, 1 year in Sweden)

P6’s excerpt demonstrates how migration influenced the meaning physical activity took on in her life, although she did not comment on whether her views would have changed had she remained in Pakistan. Participants in one group openly reflected on the meaning of physical activity noting that outdoor physical activity in their countries of origin was associated with danger and risk. They enjoyed the fact that in Sweden it was actively encouraged at school.

A disengaged perception of health education

Participants displayed disengagement towards certain health education topics. ‘Stress’ and ‘life balance’ for example, were referred to by several of the participants as prominent features of health education in Sweden. Yet participants also described these features as mainly limited to managing academic pressure, which they felt was lower in Sweden than in their country of origin. At times, participants struggled to recall whether they had covered certain topics in health education. Several indicated that they ‘may’ have talked about health topics but could describe neither the circumstances in which the topics were addressed nor the specific content that they were supposed to learn. P1’s and P5’s commentaries are illustrative:

Interviewer: Is this something you’re taught about in school here in Sweden? About eating healthy, as you said, going on diets?

P1: I think it was mentioned somewhere in science education, but I don’t remember. Maybe it was a part of the whole chemistry and biology thing, I don’t know.

(P1, female, Ukraine, 17 years old, 1.5 years in Sweden)

And in P5’s case:

Interviewer: Did [your teachers] teach you about friends and family being important?

P5: In Sweden? In school?

Interviewer: In Sweden, in school.

P5: Yeah.

Interviewer: Did they teach you about that?

P5: Yeah.

Interviewer: In what way?

P5: I think so, but I’ve forgotten it. Maybe, but I think so.

(P5, male, Gambia, 17 years old, 1.5 years in Sweden)

In contrast to P1’s and P5’s examples, where topics simply lacked meaning for the students, several participants intentionally disengaged from certain health education topics. Sex and reproduction, including consent, were specifically cited here. Participants described attending health education lessons in which these topics were covered, but only to hear ‘how other people think’. In these cases, the participants claimed that the content of Swedish health education would be incongruent with the knowledge that they learned from their families and that it was necessary for them to remain disengaged from certain messages covered in health education.

A marginalized perception of health education

The participants talked about aspects of their lives that they believed were important for health and discussed whether these aspects were addressed in Swedish health education. The participants described a number of activities, customs, and ways of being/living that they felt were important elements to being healthy but were not dealt with in school health education. These activities/customs/ways of being included: ‘knowing freedom’, ‘feeling loved by parents’, ‘feeling like one belongs’, ‘feeling safe’, ‘being social and taking time to be with family and friends’, ‘seeing the sun rise and feeling content’, and ‘respecting religion’. The participants’ extracts below show how being with friends and family is important for them, but in their view, is overlooked at school in Sweden:

Interviewer: This stuff about being happy or hanging out with friends and family and being out in the fresh air and moving like you’ve been talking about, do you learn at school that this is good for health?

P9: No. Or actually, yes, being active. But not being with family and friends and things. I haven’t heard about that.

Interviewer: You mainly learn about physical activity?

P9: Yeah, nothing else.

Interviewer: But isn’t there anywhere else in the school that you learn about how health can be related to being with friends and family?

P9: No, not actually.

P10: We don’t talk about family at school.

(P9, male, Afghanistan, 15 years old, 8 years in Sweden, P10, male, Ethiopia, 15 years old, 5 years in Sweden)

This issue was taken up later in the discussion:

P9: Yeah, we talk a lot about [nutrition] at school, in physical education.

P8: Physical education. Home economics.

P9: Home economics too.

Interviewer: And this with family and sitting together?

P11: No, not that.

P8: No, I’ve never heard that talked about in school.

Interviewer: Not even in home economics?

P11: No. They normally say: ‘Don’t sit by yourself. Sit with friends’, but nothing about the family.

Interviewer: No, but they still say, ‘Sit with friends’?

P10: In our culture we always sit together with the whole extended family.

P8: Yeah, when I eat it’s the whole extended family together.

(P8, male, Kenya, 15 years old, 4 years in Sweden; P9, male, Afghanistan, 15 years old, 8 years in Sweden; P10, male, Ethiopia, 15 years old, 5 years in Sweden; P11, female, Iran-Arabian, 16 years old, 5 years in Sweden)

Importantly, the participants did not claim that health education teachers were intentionally avoiding these topics or that health education was marginalizing health practices that the participants found important. For the participants, being loved, experiencing freedom, and feeling like one belongs were dimensions of health that occurred outside of school. If the participants reflected on it at all, they found it odd that these dimensions were not covered in health education rather than offensive or disappointing.

Discussion

The findings highlight several important issues regarding the provision of health education for young migrants in a context that assumes explicit responsibility for the wellbeing of students [20] and has been identified as an important stanchion of young people’s health [19]. Keeping with our understanding of young migrants as agents who make decisions and judgements about health knowledge but foregrounding pedagogical possibilities for health educators, we discuss three aspects of our findings: how the health education content on offer matches the students’ needs, how culture affects understandings of health and health education, and how engagement with school health education might facilitate greater engagement with health services.

The participants’ disengaged and marginalized perceptions of certain topics covered in Swedish health education helps to identify some ‘blind spots’. These two types of perceptions suggest that Swedish health education, despite the breadth of content offered [26], may miss the mark with some students who have experienced forced migration. While one might expect blind spots to concern issues such as musculoskeletal problems, sleep disorders, anxiety, and depression that have been identified in migrant health scholarship [12], these areas were not manifest in the empirical material. Topics that were ‘missing’ from health education in the participants’ descriptions were more closely associated with sustaining well-being than managing illness and disease and included psychosocial topics such as spending time with family, experiencing freedom, and feeling loved. This finding is congruent with Edge and colleagues’ [17] work, which underscored the significance of sense of belonging, positive self-identity, emotional well-being, and sense of agency to health. Our findings add credence to this work, providing young people’s descriptions of these facets of health. Importantly, the fact that these topics were not addressed in health education was puzzling rather than problematic for the participants. Many stated that they experienced or learned about these ‘healthy practices’ at home. At the same time, given the import assigned to these practices, if young people have migrated alone and/or are unable to spend time with families or ‘feel loved by parents’, the negative consequences for wellbeing are likely to be considerable [16]. School health educators should therefore consider how they include topics such as ‘feeling like one belongs’ and ‘feeling safe’ in programmes, both for students who have familial support and for those who do not.

Second, the findings provide insight into the ways that experiences prior to migration impact on understandings of health and by implication, the perceptions students develop of health education. This was evident with topics related to sex and sexuality, which from the participants’ responses, could be described as contentious. Yet even physical activity, which the participants by and large agreed was a meaningful and enjoyable topic within health education, took on varying significance in the participants’ descriptions as they related it to earlier experiences. Scholars have emphasized the impact of personal experiences on health behaviours (for example, negative experiences with medical services reducing migrants’ willingness to see health care specialists [1]). Our findings suggest that pre-migration experiences can affect more everyday health habits such as going outside during free time or eating meals. Health educators therefore would benefit from understanding learners’ personal histories before they begin to understand how students make health decisions.

Finally, it is worth acknowledging that many topics offered in health education were met with enthusiasm by the participants. This is noteworthy given that health education is a mandatory ‘offer’ [26] in Swedish schools and may contribute to the protective role that schooling plays when it comes to migrants’ health [19]. In contrast to a substantial body of literature that suggests that migrants are reluctant to seek health advice and tend to distrust medical authorities [13, 15], the participants’ enthusiastic perceptions of health education indicates that young migrants can and do develop health knowledge at school. In this respect, school health education may constitute an important step in removing barriers and building trust with health authorities, and through increased knowledge, perhaps even reducing the likelihood that young migrants need to seek health advice in the first place.

Conclusion

The aim of this paper has been to provide insights into how young people who have been forced to migrate perceive school health education. Our findings suggest three main perceptions of health education content: a moderately enthusiastic perception, a disengaged perception, and a marginalized perception. These findings: raise questions about whether the provision of health education matches the needs of these young people; highlight cultural differences in the way health topics are perceived, and; suggest that school health education might influence how young migrants deal with health authorities as they get older.

Before finishing, we would like to make four methodological reflections. First, although we have examined the ways that young migrants perceive school health education as a way of addressing a gap in the existing literature [3, 18], the participants’ descriptions should be read as interpretations. It is possible that not all participants took part in all health lessons provided by their schools due to, for example, attending alternative lessons or starting school after topics had been covered in previous years. Second, we considered using translators during interviews but decided instead to ensure that participants had a ‘friend’ who could help with communication if necessary. This decision was affected by our concern that the presence of a translator from the participant’s home country could limit participants’ willingness to discuss topics such as health care and sex education. In the event, many participants spoke Swedish or English relatively well after being in Sweden for >3 years. Communication and translation are nonetheless topics that warrant consideration in further studies of migration and potentially sensitive topics. Third, recruiting participants through their teachers means that there may have been young migrants who did not get to participate in the project, either because they were unknown to the teachers or because their teachers did not think it was appropriate for the students to participate. Our impression from the variety of participants’ characteristics and our familiarity with schools in the region is that we did not miss a certain participant perspective. Still, variation in perspectives should be investigated in further studies. Fourth, in the study we have aimed for a type of generalizability that Smith [37] refers to as transferability. Very simply, transferability refers to whether readers see how the results of the research can be applied in their own contexts. We invite transferability through direct testimony, rich description and accessible writing; however, we acknowledge that the transferability of the results will also depend on readers’ own experiences and contexts. It goes without saying that we hope that the insights provided in this paper will help health education professionals to reflect on their practices and acknowledge the voices of the people with whom they work.

Funding

This work was supported by the Swedish Research Council (grant number 2020–03309).

Conflict of interest

None declared.