Widening the scope of mental health with a 'youth centred' approach: a qualitative study involving health care professionals in Sweden's youth clinics

PURPOSE

The aim of this study was to explore how health care providers at youth clinics (YCs) in Sweden engage with, focus on, and navigate across the mental health youth space, while upholding the core bedrock principle of "youth-centeredness".

METHODS

Qualitative interviews were conducted with 21 health care professionals working in three YCs located in three different regions of Sweden. Data were analysed using reflexive thematic analysis informed by the work of Braun and Clarke.

RESULTS

The three themes were: 1) "youth mission-at the core of the YCs" work and challenged by a stronger involvement in mental ill health'; 2) "YCs" unique and complementary role in the youth mental health system: a holistic perspective, team work, and a focus on normalization', and 3) "Caught between a rock and a hard place: to treat at a care level that is not optimal for the young users" needs or to refer within an unreliable system'.

CONCLUSION

This study reflects the individuality and key features of YCs, their widening roles within the mental health sphere, and the challenges faced in maintaining and expanding the characteristic "youth-centred" approach while expanding their work with mental health.

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

BACKGROUND

Youth mental health is a major health concern in almost every country. Mental health accounts for about 13% of the global burden of disease in the 10-to-19-year age group. Still there are significant gaps between the mental health needs of young people and the quality and accessibility of available services. Collaboration between health and social service actors is a recognized way of reducing gaps in quality and access. Yet there is little scientific evidence on how these collaborations are applied, or on the challenges of cross-boundary collaboration in the youth mental health space. This study aims to explore how collaboration is understood and practiced by professionals working in the Swedish youth mental health system.

METHODS

We conducted 42 interviews (November 2020 to March 2022) with health and social care professionals and managers in the youth mental health system in Sweden. Interviews explored participants' experience and understanding of the purpose, realization, and challenges of collaboration. Data were analysed under an emergent study design using reflexive thematic analysis.

RESULTS

The analysis produced three themes. The first shows that collaboration is considered as essential and important, and that it serves diverse purposes and holds multiple meanings in relation to professionals' roles and responsibilities. The second addresses the different layers of collaboration, in relation to activities, relationships, and target levels, and the third captures the challenges and criticisms in collaborating across the youth mental health landscape, but also in growing possibilities for future development.

CONCLUSION

We conclude that collaboration serves multiple purposes and takes many shapes in the Swedish youth mental health system. Despite the many challenges, participants saw potential in further building collaboration. Interestingly our participants also raised concerns about too much collaboration. There was scepticism about collaboration directing attention away from young people to the professionals, thereby risking the trust and confidentiality of their young clients. Collaboration is not a panacea and will not compensate for an under-resourced youth mental health system.

The advancement of a gender ethics protocol to uncover gender ethical dilemmas in midwifery: a preliminary theory model

Objectives

Ethical dilemmas at both the individual and structural level are part of the daily work of midwives and gender inequality and injustice can affect women’s sexual and reproductive health. Mainstream bioethical theory has been criticized for neglecting women’s issues. To ensure women’s experiences are addressed, a gender lens on ethics is crucial.

Aim

This study develops a theory model by exploring ethical dilemmas related to gender in the context of maternity care from the perspective of midwifery science and feminist ethics.

Methods

The research strategy followed a coherent stepwise approach: literature search, thematic analysis, elaboration of a gender ethics protocol, and the integration of various components into a preliminary gender ethics model for midwifery.

Findings

A literature search was performed using Scopus and Web of Science to identify ethical dilemmas in maternity care linked to gender and power. The search of articles published between 1996 and 2019 returned 61 abstracts. These abstracts were screened and assigned one of the following themes: The Midwifery Profession, The Rights of the Woman, Fetal Rights Dominate, and Medicalization of Pregnancy and Childbirth. A tentative gender ethics frame was developed and tested on two articles on abortion, one from Denmark and one from Japan. The protocol facilitated the gender analysis of ethical dilemmas related to abortion, which were related to the imbalance of power relations in health care. In the final step, we synthesized the dimensions of gender and power in a gender ethics model for midwifery.

Discussion

The gender ethics protocol developed revealed gendered dimensions of ethical dilemmas in midwifery. This gender analysis adds to the understanding of the “do no harm” principle by revealing assumptions and stereotypes that promote unequal power relations. The gender ethics model is an innovative approach that envisions and exposes power imbalance at the micro, meso, and macro levels.

Conclusions

The protocol could improve gender competence among researchers, midwives/professionals, and midwifery students throughout the world.

A safe place - Adolescents' and young adults' perceptions of youth clinics in northern Sweden

BACKGROUND/OBJECTIVE

Adolescents and young adults are a diverse group with varied health needs. In Sweden, youth clinics are critical for improving their sexual, reproductive, mental, and general health. The aim of this qualitative study was to gain a deeper understanding of key conditions needed for youth friendliness, and to better understand youth-friendly health services from the perspective of adolescents and young adults in northern Sweden.

METHODS

Information was collected through focus group discussions and interviews with 23 adolescents and young adults (aged 16 to 25) at youth clinics in each of the four northernmost regions of Sweden. Interviews were analysed inductively using Braun and Clarke's thematic analysis.

RESULTS

Three themes and six sub-themes emerged. A safe, empowering and holistic space, outlines how youth-friendly physical spaces and staff contributed to a sense of safety in contrast to other healthcare facilities. The theme Youth clinics are accessible - but reaching out is challenging, refers to low thresholds for visiting youth clinics and perceived barriers to access. The third theme "You feel a bit vulnerable" - the importance of privacy, highlights privacy dimensions and young people's vulnerability when their privacy is compromised.

CONCLUSION

Adolescents and young adults perceived youth clinics as being youth-friendly. Key conditions for youth friendliness were safety, respect, a holistic and empowering approach, accessibility, and privacy. Youth-friendly opening hours and outreach to specifically target groups with access barriers are needed. Young people should be involved in the development of equitable youth-friendly health services.

How can we strengthen mental health services in Swedish youth clinics? A health policy and systems study protocol

INTRODUCTION

Strengthening first-line mental healthcare services for youth remains a priority for the Swedish government. The government is currently investigating how different sectors involved can be strengthened, but evidence is scarce. Youth clinics play a key role in these discussions, being one of the most trusted services for youth. However, analysis of organisational functions and coordination with other services is important to strengthen youth clinics' role in first-line mental healthcare. This study investigates these challenges and aims to analyse the integration of mental healthcare within youth clinics to identify strategies to strengthen first-line mental healthcare for youth in Sweden.

METHODS AND ANALYSIS

This study adopts a health policy and systems approach. In the first phase, a formative realist evaluation is conducted to ascertain what works in terms of integrating mental healthcare services within youth clinics, for what type of youth subpopulations and under what circumstances. National-level stakeholders will be interviewed to elicit the programme theory that explains how the intervention is supposed to work. The programme theory will then be tested in three-five cases. The cases will be comprised of youth clinics and their stakeholders. Quantitative and qualitative information will be gathered, including via visual methodologies and questionnaires. The second phase includes a concept mapping study, engaging stakeholders and young people to build consensus on strategies to strengthen the integration of mental healthcare into youth clinics.

ETHICS AND DISSEMINATION

The Swedish Ethical Review Authority has approved the study (2019-02910 and 2020-04720). The results will be published in open-access peer-reviewed journals and presented at scientific conferences.

Reproducing normative femininity: Women's evaluations of their birth experiences analysed by means of word frequency and thematic analysis

BACKGROUND

Given the significance of the birth experience on women's and babies' well-being, assessing and understanding maternal satisfaction is important for providing optimal care. While previous research has thoroughly reviewed women's levels of satisfaction with the childbirth experience from a multitude of different angles, there is a dearth of papers that use a gender lens in this area. The aim of this study is to explore through a gender perspective the circumstances attributed to both women's assessment of a positive birth experience and those which contribute to a lack of satisfaction with their birth experience.

METHODS

Through the use of a local birth evaluation form at a Swedish labour ward, 190 women gave written evaluations of their birth experiences. The evaluations were divided into groups of positive, ambiguous, and negative evaluations. By means of a latent and constructionist thematic analysis based on word count, women's evaluations are discussed as reflections of the underlying sociocultural ideas, assumptions, and ideologies that shape women's realities.

RESULTS

Three themes were identified: Grateful women and nurturing midwives doing gender together demonstrates how a gender-normative behaviour may influence a positive birth experience when based on a reciprocal relationship. Managing ambiguous feelings by sympathising with the midwife shows how women's internalised sense of gender can make women belittle their negative experiences and refrain from delivering criticism. The midwifery model of relational care impeded by the labour care organisation describes how the care women receive during labour and birth is regulated by an organisation not always adapted to the benefit of birthing women.

CONCLUSIONS

Most women were very satisfied, predominantly with emotional support they received from the midwives. The latent constructionist thematic analysis also elicited women's mixed feelings towards the birth experience, with the majority of negative experiences directed towards the labour care organisation. Recognising the impact of institutional and medical discourses on childbirth, women's birth evaluations demonstrate the benefits and challenges of gender-normative behaviour, where women's internalised sense of gender was found to affect their experiences. A gender perspective may provide a useful tool in unveiling gender-normative complexities surrounding the childbirth experience.

"A woman's honor tumbles down on all of us in the family, but a man's honor is only his": young women's experiences of patriarchal chastity norms

Purpose: In this qualitative study we explored how young women living in Sweden with ethnic and cultural roots in the Middle East and East Africa comply with or resist so-called honour norms and how they perceive that these norms affect their living conditions.

Method: In depth interviews were performed with 14 young women. The majority were between 21 and 32 years of age with a mean age of 24. All interviews were transcribed verbatim and a grounded theory approach was used. To reflect the diversity in women’s experiences, the grounded theory approach was conducted from a feminist perspective to transform women’s personal narratives to a larger social context.

Results: We analysed the core category “Honorable women in becoming” as the central emerging phenomenon related to categories about structural and individual control of women, the women’s adjustment and resistance, and the continuum of severe consequences and violence that they experienced in their struggle for autonomy.

Conclusion: Simone de Beauvoir’s feminist theory about women as “the other” was an inspiration and gave us valuable input to highlight women’s experiences and situations from a perspective of gender, power, and oppression.

Landscapes of care and despair for rural youth - a qualitative study in the northern Swedish 'periphery'

Background

This study emerges as a response to the lack of youth perspectives when it comes to discussions about access to and experiences of health and social services in rural areas. It subsequently contributes to the literature by positioning young people at the centre of this debate, and by taking a more holistic approach to the topic than is typically the case. Specifically, based on the idea that a good life in proper health for young people may be contingent on notions of care that are bounded up in multi-layered social and spatial environments, the aim of this study was to explore what characterises ‘landscapes of care’ for rural youth.

Methods

In this qualitative study, the participants included young people and professionals residing in five diverse areas across the northern Swedish ‘peripheral’ inland. Individual interviews (16 in total) and focus group discussions (26 in total) were conducted with 63 youth aged 14–27 years and with 44 professionals operating across sectors such as health centres, school health, integration units, youth clinics and youth clubs. Following an emergent design and using thematic analysis, we developed one main theme, ‘landscapes of care and despair’, comprising the two themes: ‘(dis)connectedness’ and ‘extended support or troubling gaps’.

Results

The findings illustrate how various health-promoting and potentially harmful aspects acting at structural, organisational and interpersonal levels contributed to dynamic landscapes characterised simultaneously by care and despair. In particular, our study shows how rural youths’ feelings of belongingness to people and places coupled with opportunities to participate in society and access practical and emotional support appear to facilitate their care within rural settings. However, although the results indicate that some in the diverse group of rural youth were cared for and about, a negative picture was painted in parallel. These aspects of despair included youths’ senses of exclusion and marginalisation, degrading attitudes towards them and their problems, as well as recurrent gaps in the provision and practices of care.

Conclusions

To gain a more comprehensive understanding about the health of rural youth, this study highlights the benefits investigating ‘care-ful’ and ‘uncaring’ aspects bounded up in dynamic and multi-layered landscapes.

Exploring the medicalisation of childbirth through women's preferences for and use of pain relief

BACKGROUND

Sweden, along with other countries, is facing rising intrapartum intervention rates.

AIM

To explore the medicalisation of childbirth through women's preferences for and use of pain relief, and to investigate whether the presence of a birth plan had any impact on use of pain relief, rate of intervention, and satisfaction with the birth experience.

METHODS

The study was cross-sectional, and included 129 women with birth plans and 110 without, all of whom gave birth in one hospital in Sweden between March and June 2016. Data from birth plans and medical records was analysed through descriptive statistics and logistic regression.

FINDINGS

Parity rather than birth plan was a greater determinant for use of pain relief, frequency of interventions, and level of satisfaction; primiparas used more pain relief, had more interventions, and were less satisfied with their birth experiences than multiparas. Epidural analgesia was associated with a two to threefold increase in interventions, but 79.5% of all women had some form of intervention during birth, regardless of having an epidural or not. Women were generally highly satisfied with their birth experiences, women without epidural analgesia and interventions slightly more so.

CONCLUSION

Contrary to their initial plans, especially primiparas used more pharmacological pain relief than intended, and nearly all (94.6%) had some form of intervention during labour and birth. More interventions were associated with lower levels of satisfaction. The high rate of intervention in a healthy population of birthing women is disquieting and requires further attention.

Accessibility and factors associated with utilization of mental health services in youth health centers. A qualitative comparative analysis in northern Sweden

Background

Youth-friendly health care services can facilitate young people's access to health care services and promote their health, including their mental health. In Sweden, a network of youth health centers exist since the 1970s, incorporated within the public health system. Even if such centers take a holistic approach to youth health, the focus has been in sexual and reproductive health care, and the extent of integrating mental health care services is less developed though it varies notably between different centers. This study aims to analyse the various conditions that are sufficient and/or necessary to make Swedish youth health centers accessible for mental and psychosocial health.

Methods

Multiple case study design, using qualitative comparative analysis to assess the various conditions that makes a youth health center accessible for mental and psychosocial issues and mental health. The cases included 18 youth health centers (from a total of 22) in the four northern counties of Sweden.

Results

In order to enhance accessibility for mental health services, youth health centers need to be trusted by young people. Trust was necessary but not sufficient, meaning that it had to be combined with other conditions: either having a team with a variety of professions represented in the youth health center, or being a youth health center that is both easy to contact and well-staffed with mental health professionals.

Conclusions

Differentiated, first-line services for youth can play an important role in promoting youth mental health if certain conditions are fulfilled. Trust is necessary, but has to be combined with either multidisciplinary teams, or expertise on mental health and easy accessibility.

Autonomous and dependent-The dichotomy of birth: A feminist analysis of birth plans in Sweden

OBJECTIVE

To elicit pregnant women's perceptions of childbirth as expressed in their birth plans, and through a feminist lens analyse their wishes, fears, values, and beliefs about childbirth, as well as their expectations on partner and midwife.

DESIGN

This study used qualitative content analysis, identifying subcategories, categories, and an overall theme in data gathered from women's written birth plans. A feminist theoretical framework underpinned the research.

SETTING

A middle-sized city in northern Sweden.

PARTICIPANTS

132 women who gave birth in an obstetrician-led hospital labour ward between March and June 2016 and consented to grant access to their birth plans and antenatal and intrapartum electronic medical records.

FINDINGS

Three categories emerged: 'Keeping integrity intact through specific requests and continuous dialogue with the midwife', 'A preference towards a midwife-supported birth regardless of method of pain relief", and '"Help my partner help me" - Women anticipating partner involvement.' The overall theme linking the categories together was: 'Autonomous and dependent - The dichotomy of birth', portraying women's ambiguity before birth -expressing a wish to remain in control while simultaneously letting go of control by entrusting partner and midwifewith decision-making regarding their own bodies.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Women primarily desired a natural, midwife-supported birth and favoured a relationship-based, woman-centred model of care, based on the close interaction between woman, partner, and midwife. Midwives need to be aware of women's ambiguous reliance on them and the power they have to influence women's birth choices and birth experiences. Feminist theory and values in midwifery practice may be useful to inspire a maternity care based on women's wishes and expectations, acknowledging and valuing women's voices, and embracing the sanctity of birth and of the birthing woman's body.

Prevalence and correlates of gender inequitable norms among young, church-going women and men in Kinshasa, Democratic Republic of Congo

Background

Prolonged political instability may have exacerbated gender inequitable beliefs in the Democratic Republic of Congo (DRC). The aim of this study was to assess attitudes related to gender-equitable norms and its determinants among young, church-going women and men in Kinshasa, DRC.

Method

Data were collected through a cross-sectional survey with 291 church-going women and 289 men aged 18–24 years old, residing in three disadvantaged communes of Kinshasa. Variables included sociodemographic characteristics, attitudes towards gender equality, and responses to issues related to the gender-equitable men (GEM) scale. The GEM scale is a 24 item-questionnaire developed to measure attitudes towards gender equitable norms. Logistic regression was applied to discover the associations between the independent variables and the GEM outcome.

Results

Our study reflected the existence of attitudes hampering gender equality that were endorsed by both women and men. For example, 91.4% of women and 83% of men agreed with the statement “a woman’s most important role is to take care of her home and cook for her family”. Similarly, 88.3% of women and 82.9% of men concurred with the idea that men need more sex than women. These findings coexisted with a few equitable norms, because 93.7% of women and 92.3% of men agreed that a man and a woman should decide together if they want to have children. A positive association was found in both women and men between being educated, being single and separated and having supportive attitudes towards gender equality and a higher GEM scale score. Residency in Camp Luka and Masina was also a significant social determinant associated with equitable gender norms among men whilst job status was only significant among women.

Conclusion

While both women and men had high levels of gender inequitable norms, those with more education, single, and with supportive attitudes to gender equality had high GEM scale scores. The results highlight an urgent need for the church to challenge and change gender norms among church youths.

Health care access for rural youth on equal terms? A mixed methods study protocol in northern Sweden

Background

The purpose of this paper is to propose a protocol for researching the impact of rural youth health service strategies on health care access. There has been no published comprehensive assessment of the effectiveness of youth health strategies in rural areas, and there is no clearly articulated model of how such assessments might be conducted. The protocol described here aims to gather information to; i) Assess rural youth access to health care according to their needs, ii) Identify and understand the strategies developed in rural areas to promote youth access to health care, and iii) Propose actions for further improvement. The protocol is described with particular reference to research being undertaken in the four northernmost counties of Sweden, which contain a widely dispersed and diverse youth population.

Methods

The protocol proposes qualitative and quantitative methodologies sequentially in four phases. First, to map youth access to health care according to their health care needs, including assessing horizontal equity (equal use of health care for equivalent health needs,) and vertical equity (people with greater health needs should receive more health care than those with lesser needs). Second, a multiple case study design investigates strategies developed across the region (youth clinics, internet applications, public health programs) to improve youth access to health care. Third, qualitative comparative analysis of the 24 rural municipalities in the region identifies the best combination of conditions leading to high youth access to health care. Fourth, a concept mapping study involving rural stakeholders, care providers and youth provides recommended actions to improve rural youth access to health care.

Discussion

The implementation of this research protocol will contribute to 1) generating knowledge that could contribute to strengthening rural youth access to health care, as well as to 2) advancing the application of mixed methods to explore access to health care.

Factors associated with gender equality among church-going young men in Kinshasa, Democratic Republic of Congo: a cross-sectional study

Background

While women and girls are made vulnerable by inequitable and violent versions of masculinities, there is increasing evidence that gender equality will not be achieved without partnering with men. The aim of this study was to assess gender-equitable norms and their determinants among church-going young men in Kinshasa, the Democratic Republic of Congo.

Method

A cross-sectional study was carried out among 289 church-going young men, aged 18–24 years, residing in three disadvantaged communes of Kinshasa. Variables included sociodemographic characteristics, attitudes towards gender equality and responses to issues related to the Gender-Equitable Men (GEM) scale. Logistic regression was applied to identify the associations between sociodemographic characteristics, attitudes and the GEM scale.

Results

The findings provide evidence of attitudes and beliefs that act as barriers to gender equality. For instance, the majority of church-going young men (83.74%) agreed that a man is the only decision maker in the home and about half (50.87%) of the respondents supported the statement “There are times a woman deserves to be beaten”. Similarly, around half of the participants agreed with the idea of men’s uncontrollable sex drive (50.87%) and men’s toughness (50.17%). Close to half of the participants (44.29%) agreed that it is women’s responsibility to prevent pregnancy. These attitudes co-existed with a few gender-equitable norms as 82.70% agreed on the importance of joint decisions concerning family planning. An association between education, certain places of residence, being single or separated, and supportive attitudes towards gender equality was found with higher scores for the GEM.

Conclusion

Our study findings indicate that a high proportion of church-going young men do not endorse gender-equitable norms. Therefore, churches urgently need comprehensive gender equality and masculinity policies and programmes to influence young men’s attitudes and behaviours. The promotion of gender equality in schools and the wider community also need to be encouraged.

"Men don't think that far" - Interviewing men in Sweden about chlamydia and HIV testing during pregnancy from a discursive masculinities construction perspective

OBJECTIVES

We used qualitative research design to discursively explore expectant fathers' perceptions of chlamydia and HIV, and their masculinity constructions about testing, and explored how they talked about their potential resistance towards testing and their pre-test emotions.

STUDY DESIGN

Twenty men were offered chlamydia and HIV testing at the beginning of their partner's pregnancy. Those who agreed to be tested were interviewed in-depth; those who declined testing were also interviewed. The interviews were tape recorded and transcribed verbatim. The analysis was inspired by discourse analysis on masculinity.

MAIN OUTCOME

Three discursive themes: Men prefer to suppress their vulnerability to STIs, Body and biology differ between men and women and Men have mixed emotions around STI testing underscore the informants' conversations and sometimes conflicting thoughts about STI testing.

CONCLUSION

The majority of men talked about pregnancy as a feminine territory, raised uncertainties about men's roles in the transmission of STIs, and talked about women's and men's essentially different bodies and biology, where few men realised that they could infect both their partner and the unborn child. This knowledge gap that men have must become apparent to healthcare providers, and policy makers must give men equal access to the reproductive arena.

Church representatives' perspectives on masculinities in the context of HIV: the case of the Ecumenical HIV and AIDS Initiative in Africa

Despite a growing body of literature related to church leaders challenging dominant norms of masculinities that may enable the spread of HIV, research on masculinity issues among African church representatives who are policy makers is scarce. The objectives of this study were to explore the perspectives on masculinities held by church representatives within the Ecumenical HIV and AIDS Initiative in Africa (EHAIA) and to identify strategies they used to transform masculinities in their respective churches. Qualitative interviews were carried out with 14 church representatives belonging to the EHAIA International Reference Group. These interviews were analysed using thematic analysis and four themes were identified: "barriers to challenge masculinities" may contribute to the spread of HIV; "counterproductive conservative church leadership" fails to challenge dominant forms of masculinities; "facilitators to challenge masculinities" perceived as slowly changing men and "an evolving hope for gender equality" would be perceived in certain marital relationships. The latter two were viewed as positive approaches resulting from masculinity workshops and male priests disclosing their HIV-positive status. This research highlights strategies that may help male church-goers challenge masculinities, support gender equality and, improve the lives of men and women in the context of HIV.

Challenges and strategies for sustaining youth-friendly health services - a qualitative study from the perspective of professionals at youth clinics in northern Sweden

Background

Youth-friendly health-care services — those that are accessible, acceptable, equitable, appropriate and effective for different youth subpopulations – are beneficial for youth health, but not easy to implement and sustain. Sweden is among the few countries where youth-friendly health-care services have been integrated within the public health system and sustained for a long time.

This study explores the challenges and strategies in providing sustainable youth-friendly health-care services, from the perspective of professionals working in youth clinics in northern Sweden.

Methods

Eleven semi-structured interviews with various health-care professionals working in youth clinics in northern Sweden were conducted. The interviews were transcribed verbatim, and analysed using thematic analysis in relation to the World Health Organization domains of youth friendliness.

Results

Four themes emerged from the analysis of the data: 1) ‘Meeting youths on their own terms – the key to ensuring a holistic and youth-centred care’ was related to the acceptability and appropriateness of the services; 2) ‘Organizational challenges and strategies in keeping professionals’ expertise on youth updated’ referred to the domain of effectiveness; 3) ‘Youth clinics are accessible for those who know and can reach them’ was related to the domains of accessibility and equity, and 4) ‘The challenge of combining strong directions and flexibility in diverse local realities’ focused on the struggle to sustain the youth clinics organization and their goals within the broader health system.

Conclusions

Professionals working in youth clinics are perceived as motivated, interested and knowledgeable about youth, and the clinics ensure confidentiality and a youth-centred and holistic approach. Challenges remain, especially in terms of ensuring equitable access to different youth subpopulations, improving monitoring routines and ensuring training and competence for all professionals, independently of the location and characteristics of the clinic. Youth clinics are perceived as an indisputable part of the Swedish health system, but organizational challenges are also pointed out in terms of weak clear directives and leadership, heavy workload, local/regional diversity and unequitable distribution of resources.

Electronic supplementary material

The online version of this article (doi:10.1186/s12978-016-0261-6) contains supplementary material, which is available to authorized users.

``Eyes Wide Shut'' — Sexuality and risk in HIV-positive youth in Sweden: A qualitative study

Aims: This study explores the perception of sexual risk-taking behaviour in young HIV+ women and men in Sweden and their understanding of why they caught HIV. Method: In-depth interviews were conducted with 10 HIV+ women and men aged 17—24 years, 7 born in Sweden and 3 immigrants. Interviews were tape-recorded, transcribed verbatim, and analysed according to the stages of grounded theory. Results: The core category varying agency in the gendered sexual arena illustrated a spectrum of power available to these informants during sexual encounters. Two subcategories contextualized sexual practice: sociocultural blinds and from consensual to forced sex. Lack of adult supervision as a child, naïve views, being in love, alcohol and drugs, the macho ideal, and cultures of silence surrounding sexuality both individually and structurally all blinded them to the risks, making them vulnerable. Grouping narratives according to degree of consensus in sexual encounters demonstrated that sexual risks happened in a context of gendered power relations. Conclusion: This pioneering study reveals mechanisms that contribute to vulnerability and varied agency that may help in understanding why and how young people are at risk of contracting HIV. Public health strategies, which consider the role of gender and social background in the context of risky behaviours, could be developed from these findings.

Searching for best practices of youth friendly services - a study protocol using qualitative comparative analysis in Sweden

Background

Swedish youth clinics constitute one of the most comprehensive and consolidated examples of a nationwide network of health care services for young people. However, studies evaluating their ‘youth-friendliness’ and the combination of factors that makes them more or less ‘youth-friendly’ have not been conducted. This protocol will scrutinise the current youth-friendliness of youth clinics in northern Sweden and identify the best combination of conditions needed in order to implement the criteria of youth-friendliness within Swedish youth clinics and elsewhere.

Methods/design

In this study, we will use qualitative comparative analysis to analyse the conditions that are sufficient and/or necessary to implement Youth Friendly Health Services in 20 selected youth-clinics (cases). In order to conduct Qualitative Comparative Analysis, we will first identify the outcomes and the conditions to be assessed. The overall outcome – youth-friendliness – will be assessed together with specific outcomes for each of the five domains – accessible, acceptable, equitable, appropriate and effective. This will be done using a questionnaire to be applied to a sample of young people coming to the youth clinics. In terms of conditions, we will first identify what might be the key conditions, to ensure the youth friendliness of health care services, through literature review, interviews with professionals working at youth clinics, and with young people. The combination of conditions and outcomes will form the hypothesis to be further tested later on in the qualitative comparative analysis of the 20 cases. Once information on outcomes and conditions is gathered from each of the 20 clinics, it will be analysed using Qualitative Comparative Analysis.

Discussion

The added value of this study in relation to the findings is twofold: on the one hand it will allow a thorough assessment of the youth-friendliness of northern Swedish youth clinics. On the other hand, it will extract lessons from one of the most consolidated examples of differentiated services for young people. Methodologically, this study can contribute to expanding the use of Qualitative Comparative Analysis in health systems research.

Promoting women's human rights: A qualitative analysis of midwives' perceptions about virginity control and hymen 'reconstruction'

OBJECTIVES

To explore midwives' perceptions regarding virginity control and hymen 'reconstructions', and how these practices can be debated from a gender perspective.

METHODS

An international group of 266 midwives answered an open-ended question in a Web survey. The great majority came from the Western world, among them, the majority were from Europe. Data were analysed using qualitative content analysis.

RESULTS

Three themes emerged: misogynistic practices that cement the gender order, which revealed how the respondents viewed virginity control and hymen 'reconstructions'; raising public awareness and combatting practices that demean women, which were suggested as strategies by which to combat these practices; and promoting agency in women and providing culturally sensitive care, which were considered to improve health care encounters.

CONCLUSIONS

Virginity control and hymen 'reconstructions' are elements of patriarchy, whereby violence and control are employed to subordinate women. To counter these practices, macro and micro-level activities are needed to expand women's human rights in the private and the public spheres. Political activism, international debates, collaboration between sectors such as health care and law-makers may lead to increased gender equality. A women-centred approach whereby women are empowered with agency will make women more capable of combatting virginity control and hymen 'reconstruction'.

Conflicting discourses of church youths on masculinity and sexuality in the context of HIV in Kinshasa, Democratic Republic of Congo

Masculinity studies are fairly new and young churchgoers are an under-researched group in the current Congolese church context. In response to this knowledge gap, this paper attempts to explore discourses of young churchgoers from deprived areas of Kinshasa regarding masculinity and sexuality in the era of HIV. A series of 16 semi-structured interviews were conducted with unmarried young churchgoers from the Salvation Army, Protestant and Revival churches. The interviews were tape-recorded, transcribed verbatim and analysed using discourse analysis. Five main discourses emerged: 'we are aware of the church message on sex', 'young men need sex', 'young women need money', 'to use or not to use condoms' and 'we trust in the church message'. Although all informants knew and heard church messages against premarital sex, many of them were sexually active. The perception was that young men were engaged in sexual activities with multiple partners as a result of sexual motivations surrounding masculinity and sexual potency, while young women sought multiple partners through transactional and intergenerational sex for economic reasons. These sexual practices of young people conflicted with church messages on sexual abstinence and faithfulness. However, a small number of participants challenged current gender norms and suggested alternative ways of being a man or a woman. To elucidate these alternatives, we suggest that church youths and church leaders might take concrete actions to deconstruct misconceptions about being men. In this way, they can possibly enhance a frank and fruitful dialogue on sex, sexuality and gender to promote positive masculinities and constructive partnerships to prevent HIV.

"Not used but almost…"--a gender and agency analysis of the grey zone between consensual and nonconsensual sexual intercourse

Rape is a widespread but underreported problem among women. In this article I explore the complexities surrounding the fine line between consensual and nonconsensual sexual intercourse, by studying a rape through which a young woman was infected with HIV. I provide an analysis of how to understand and interpret this episode by applying a gender perspective based on patriarchy-namely, women's submissive position in heterosexual situations compared with men-and the concept of agency, that is, the individual's own decision-making ability, own choices, and different courses of action available, to outline the frame of action available to the informant. The inclusion of agency and a gender perspective offers new dimensions on how to understand and give meaning to narratives that are seldom told.

Central gender theoretical concepts in health research: the state of the art

Despite increasing awareness of the importance of gender perspectives in health science, there is conceptual confusion regarding the meaning and the use of central gender theoretical concepts. We argue that it is essential to clarify how central concepts are used within gender theory and how to apply them to health research. We identify six gender theoretical concepts as central and interlinked-but problematic and ambiguous in health science: sex, gender, intersectionality, embodiment, gender equity and gender equality. Our recommendations are that: the concepts sex and gender can benefit from a gender relational theoretical approach (i.e., a focus on social processes and structures) but with additional attention to the interrelations between sex and gender; intersectionality should go beyond additive analyses to study complex intersections between the major factors which potentially influence health and ensure that gendered power relations and social context are included; we need to be aware of the various meanings given to embodiment, which achieve an integration of gender and health and attend to different levels of analyses to varying degrees; and appreciate that gender equality concerns absence of discrimination between women and men while gender equity focuses on women's and men's health needs, whether similar or different. We conclude that there is a constant need to justify and clarify our use of these concepts in order to advance gender theoretical development. Our analysis is an invitation for dialogue but also a call to make more effective use of the knowledge base which has already developed among gender theorists in health sciences in the manner proposed in this paper.

Beyond a dichotomous view of the concepts of 'sex' and 'gender' focus group discussions among gender researchers at a medical faculty

Introduction

The concepts of ‘sex’ and ‘gender’ are both of vital importance in medicine and health sciences. However, the meaning of these concepts has seldom been discussed in the medical literature. The aim of this study was to explore what the concepts of ‘sex’ and ‘gender’ meant for gender researchers based in a medical faculty.

Methods

Sixteen researchers took part in focus group discussions. The analysis was performed in several steps. The participating researchers read the text and discussed ideas for analysis in national and international workshops. The data were analysed using qualitative content analysis. The authors performed independent preliminary analyses, which were further developed and intensively discussed between the authors.

Results

The analysis of meanings of the concepts of ‘sex’ and ‘gender’ for gender researchers based in a medical faculty resulted in three categories; “Sex as more than biology”, with the subcategories ‘sex’ is not simply biological, ‘sex’ as classification, and ‘sex’ as fluid and changeable; ”Gender as a multiplicity of power-related constructions”, with the subcategories: ‘gender’ as constructions, ‘gender’ power dimensions, and ‘gender’ as doing femininities and masculinities; “Sex and gender as interwoven”, with the subcategories: ‘sex’ and ‘gender’ as inseparable and embodying ‘sex’ and ‘gender’.

Conclusions

Gender researchers within medicine pointed out the importance of looking beyond a dichotomous view of the concepts of ‘sex’ and ‘gender’. The perception of the concepts was that ‘sex’ and ‘gender’ were intertwined. Further research is needed to explore how ‘sex’ and ‘gender’ interact.

Sex and gender traps and springboards: a focus group study among gender researchers in medicine and health sciences

We explored the difficulties that gender researchers encounter in their research and the strategies they use for solving these problems. Sixteen Swedish researchers, all women, took part in focus group discussions; the data were analyzed using qualitative content analysis. The problems reported fell into four main categories: the ambiguity of the concepts of sex and gender; traps associated with dichotomization; difficulties with communication; and issues around publication. Categories of suggested problem-solving strategies were adaptation, pragmatism, addressing the complexities, and definition of terms. Here the specific views of gender researchers in medicine and health sciences-"medical insiders"-bring new challenges into focus.

A girl thing: perceptions concerning the word "hymen" among young Swedish women and men

INTRODUCTION

This study investigated, from a gender perspective, perceptions concerning the word "hymen" among students in a Swedish senior high school.

METHODS

Students answered an open-ended question: What do you think about when you hear the word hymen? The answers were analyzed by using content analysis.

RESULTS

In total, 198 students, aged 17 to 18 years, answered the question. The theme "a fragile biological structure in the female body" described how the vast majority of the girls and 57% of the boys associated the hymen with a thin membrane that breaks during first vaginal intercourse. The theme "a symbol and manifestation of feminine virginity" described the symbolic meanings of having or not having a hymen. The theme "questioning the existence of the hymen" revealed the doubts that some had about its existence.

DISCUSSION

Most of the students associated the hymen with a breakable membrane. This is problematic. It may lead to misunderstandings about virginity or about bleeding during sexual intercourse. Changing these views about the hymen is important to correct such misunderstanding but may be a significant challenge. In modern medical discourse, in health care, and in popular speech, there are few discussions about the hymen as a social construct, indicating that more gender research concerning hymen-related issues is needed.

Concepts of risk among young Swedes tested negative for HIV in primary care

OBJECTIVE

To explore why young adults test for HIV, how they construct the HIV risk, and what implications testing has for them.

DESIGN

Six tape-recorded focus-group interviews were transcribed verbatim and analysed according to a grounded theory approach.

SUBJECTS AND SETTING

Women and men between 18 and 24 years of age were recruited from a youth clinic in northern Sweden in 2004-05 after being tested and found to be HIV negative.

RESULTS

A core category--reconsidering risk and four categories--HIV: a distant threat; the risk zone; responsibility: a gendered issue; a green card-- emerged. HIV was described as being far away. Stereotypical images of risk actors emerged but were perceived to be clichés. "Ordinary" people including themselves were also considered at risk. Many had event-driven reasons for testing for HIV, multiple partners being one. One closer risk zone was "the bar"; a dating milieu that often was expected to include "one-night stands" for both women and men. Responsibility for testing was a gendered issue: it was "natural" for women, while men rather "escaped from responsibility". A resistance towards testing was revealed among young men. Receiving a negative HIV test result was "a green card", confirming healthiness and providing relief. Most informants felt "clean" and discussed how to restart with renewed ambitions.

CONCLUSIONS

As participating in focus-group interviews was apparently an "eye-opener" for many, a counselling conversation reconsidering risk following an HIV test might be a good idea. Liberal HIV testing among young men and women could evoke insights and maturation and start a process of reflections concerning their sexual risk-taking behaviour.

"One-night stands" - risky trips between lust and trust: qualitative interviews with Chlamydia trachomatis infected youth in North Sweden

AIM

The aim of the study was to get a deeper understanding of sexual risk-taking, by interviewing young people diagnosed with Chlamydia trachomatis.

METHOD

This qualitative study was conducted at a youth clinic in Umeå, Sweden. Five young women and four men, aged 18-22, participated. In-depth interviews were performed. Open questions around certain themes were posed, such as thoughts about getting CT, sexual encounters, and attitudes towards condoms. Interviews were tape-recorded and transcribed verbatim. Data were analysed according to grounded theory. Norms, events, and emotions were explored. The goal was to develop credible and applicable concepts concerning sexual relationships, risk-taking, and experiences of CT.

RESULTS

Informants revealed that behind their sexual risk-taking was a drive to "go steady". Lust and trust were the guidelines if sex was going to take place. When discussing "one-night stands" gender stereotypes occurred. Females were expected to be less forward compared with males. We found an uneven distribution of responsibility concerning condoms. Males expected females to be "condom promoters". By catching CT, females experienced guilt, while males felt content through knowing "the source of contamination".

CONCLUSION

An important public health issue is to implement how males should play an equal part in reproductive health. General CT screening of males is one suggestion.

Carbon isotopic ratios of atmospheric CO(2) affect the delta(13)C values of heterotrophic growth in Nicotiana tabacum

Heterotrophic Nicotiana tabacum (L. CV. Wisconsin 38) plants are enriched in 13C relative to the carbon sources in their growth medium. We examined whether carboxylation via phosphoenolpyruvate carboxylase contributes to the enrichment. Achlorophyllous plants were produced using an inhibitor of carotenoid synthesis and were grown on sucrose with known delta(13)C values. Groups of plants were exposed to air with different delta(13)C values as well as to CO(2)-free air. The delta(13)C values of heterotrophic plants were greater than the sucrose source in all treatments and this enrichment increased as 13CO(2)/12CO(2) ratios increased in the source air. Rubisco activity was ruled out as a cause for the enrichment observed as 13CO(2)/12CO(2) ratios increased because the delta(13)C values of heterotrophic plants were similar when exposed to high 13CO(2) while grown in the light or dark. Neither was enrichment due to the adsorption of 13CO(2) in the high 13CO(2) treatment because dead plants did not exhibit this effect when subjected to the same atmospheric treatments. Carboxylation by PEP carboxylase is a likely mechanism causing the 13C-enriched values of living white tissues relative to their organic carbon sources. These results experimentally support suggestions that the anaplerotic activity of PEP is responsible for the 13C-enrichment commonly observed where heterotrophic inputs to growth are large such as in very young leaves.

The quantitative response to cytokinin in the moss Funaria hygrometrica does not reflect differential sensitivity of initial target cells

Exposure to sufficient cytokinin induces the formation of buds from responsive cells in the protonema of Funaria hygrometrica. Initial perception of the phytohormone results in a Ca+2 cascade within minutes. A second cytokinin-mediated event occurs some days later, and converts incipient buds into stably committed buds. The concentration of exogenous cytokinin also regulates the total number of buds produced from a protonemal colony. This concentration-dependent production of buds has been thought to reflect differential sensitivity of target cells. Under that hypothesis, the regulation of bud number occurs during initial perception of hormone. This paper presents direct experimental evidence to the contrary and supports the alternate hypothesis that bud formation involves the gating of large numbers of responding cells by later events. Experiments transferring protonema between media with different levels of cytokinin show that the cytokinin concentration during the initial perception of cytokinin is unimportant in controlling bud number. Instead, bud number is found to be regulated by the concentration of exogenous cytokinin as incipient buds or bud initials become stably committed buds.

Microvascularized free fibular grafts for reconstruction of skeletal defects after tumor resection

A microvascularized free fibular graft was used to reconstruct a skeletal defect after tumor reconstruction in 13 consecutive patients. The patients were evaluated at an average follow-up of 53 months (range, 30-71). The status of each graft was evaluated for time to union, hypertrophy, functional evaluation, and complications. The average time to union was 6.5 months, and significant graft hypertrophy occurred in eight of 13 patients. Complications occurred in seven patients. Two of the 13 patients required removal of the microvascularized graft. Functional evaluation according the the Musculoskeletal Tumor Society yielded an average score of 90 (range, 83-97). The results were rated good or excellent in 11 of 13 patients, and two were rated failures. The microvascularized fibular graft provides an attractive option for the reconstruction of skeletal defects after tumor resection. The results of this procedure are especially good in skeletally immature patients.

A successful tobacco cessation program led by primary care nurses in a managed care setting

We conducted a descriptive study of a tobacco cessation program sponsored by a health maintenance organization (HMO) and led by primary care nurses. The tobacco cessation program was conducted at 20 primary care clinics in northeastern and central Pennsylvania. We gauged the successfulness of the program by the patients' self-reported quit rates at 1 year. We also examined the association between quit rates and compliance with scheduled counseling visits, the impact of the availability of an HMO pharmacy benefit that supported the costs of nicotine replacement therapy, and the quit rates among patients with HMO insurance versus those with insurance other than managed care. Of 1,695 patients enrolled in the program from July 1993 to March 1996, 1,140 completed 1 year of follow-up. Of these, 348 (30.5%) reported they had quit using tobacco. Among the 810 HMO enrollees who participated in the program, the quit rate was 280 (34.6%); among the 330 non-HMO participants, the quit rate was 69 (20.9%), a statistically significant difference (P < 0.001). For all patients, keeping more than four visits with the program nurse was associated with a significantly higher likelihood of quitting (317/751 [42.2%] versus 32/389 [8.2%]; P < 0.001). Non-HMO patients were less likely than HMO enrollees to keep four or more visits (165 [50%] versus 586 [72.3%]; P < 0.001). We were unable to detect a difference in quit rates among those with and those without a pharmacy benefit (196/577 [34%] versus 84/233 [36.1%]). These data are limited by their descriptive nature and the lack of information about other factors important in determining the quit rate among program participants. Nevertheless, they suggest that HMOs can successfully sponsor nurse-led tobacco cessation programs in multiple primary care settings and achieve 1-year quit rates significantly higher than the 15% quit rate reported in the medical literature. In addition, successfully quitting tobacco use appeared to be associated with use of counseling visits but not with use of a pharmacy benefit to pay for nicotine replacement therapy. Even though tobacco cessation programs have the best chance of benefitting HMO enrollees, patients not enrolled in managed care plans also appear to benefit significantly. This finding has important implications for developing future strategies--including the role of managed care organizations, the need to defray the costs of nicotine replacement therapy, and the best approach to provide counseling to patients--to meet the Healthy People 2000 goal of reducing tobacco smoking.

Ultrasonic characteristics of frozen liver

The recent development of new ultrasound probes has made real-time intraoperative monitoring of cryosurgery, and thermocouple placement a possibility. It is shown that frozen tissue and thermocouple needles have acoustic characteristics that enable them to be easily visualized by ultrasound examination. Further in vivo animal studies are needed to examine temperature characteristics of visualized cryolesions, to develop scanning techniques, and to correlate ultrasonic findings with histologic changes in tissue.

Intra-operative hyphema: a complication of retinal detachment surgery with the Choyce pseudo-phakos

During retinal reattachment surgery in an eye with a Choyce pseudo-phakos a large hyphema developed. The probable mechanism was rupture of blood vessels in the angle of the anterior chamber during drainage of sub-retinal fluid as all the eye structures collapsed around the rigid pseudo-phakos.