Exposure to culturally sensitive sexual health information and impact on health literacy: a qualitative study among newly arrived refugee women in Sweden

Abstract

In Sweden, migrants have poorer sexual and reproductive health compared to the general population. Health literacy, in the form of the cognitive and social skills enabling access to health promoting activities, is often poorer among migrants, partly due to language and cultural barriers. Culturally sensitive health education provides a strategy for enhancing health literacy. Since 2012, specially trained civic and health communicators have provided sexual and reproductive health and rights information to newly arrived refugees in Skåne, Sweden. The aim of this study was to explore how information on sexual and reproductive health and rights was perceived by female recipients and whether being exposed to such information contributed to enhanced sexual and reproductive health and rights literacy. Semi-structured in-depth interviews were conducted with nine women and analysed using qualitative content analysis. Two themes emerged: (1) opening the doors to new understandings of sexual and reproductive health and rights and (2) planting the seed for engagement in sexual and reproductive health and rights issues, illustrating how cultural norms influenced perceptions, but also how information opened up opportunities for challenging these norms. Gender-separate groups may facilitate information uptake, while discussion concerning sexual health norms may benefit from taking place in mixed groups.

Résumé

En Suède, le niveau de santé sexuelle et reproductive est plus faible parmi les migrants que dans la population générale. Les connaissances sur la santé, à travers des aptitudes cognitives et sociales qui permettent l’accès à des activités de promotion de la santé, sont également plus faibles chez les migrants, notamment en raison des barrières linguistiques et culturelles. Depuis 2012, des spécialistes de la communication civique et sur la santé fournissent aux réfugiés nouvellement arrivés dans le comté suédois de Scanie de l’information sur la santé sexuelle et reproductive, et sur les droits sexuels. L’objectif de cette étude était d’examiner comment cette information était perçue par ses destinataires de sexe féminin et de vérifier si l’exposition à cette information contribuait à l’amélioration des connaissances sur la santé sexuelle et reproductive et sur les droits sexuels. Des entretiens en profondeur semi-structurés ont été conduits avec neuf femmes puis analysés dans une approche qualitative de leur contenu. Deux thèmes ont émergé – ouvrant la voie à de nouvelles compréhensions de la santé sexuelle et reproductive et des droits sexuels, et semant les graines de l’implication sur les questions relatives à ces sujets – qui montrent comment les normes culturelles influencent les perceptions, mais également comment l’information offre des opportunités de remise en question de ces normes. Des groupes distincts selon le genre peuvent renforcer l’assimilation de l’information, tandis que la discussion sur les normes de santé sexuelle peut être facilitée par la participation à des groupes mixtes.

Resumen

En Suecia, los inmigrantes tienen una peor salud sexual y reproductiva que la población en general. Con frecuencia el nivel de información sobre asuntos sanitarios, en forma de habilidades cognitivas y sociales que permiten el acceso a actividades para fomentar la salud, es peor entre los inmigrantes, en parte debido al idioma y las barreras culturales. Una educación sanitaria que tenga en cuenta los diferentes factores culturales ofrece una estrategia para mejorar la información sanitaria. Desde 2012, comunicadores especialmente formados sobre asuntos cívicos y sanitarios han ofrecido información sobre salud y derechos sexuales y reproductivos a refugiados recién llegados a Skåne, Suecia. El objetivo de este estudio fue analizar cómo inmigrantes femeninas recibían la información sobre salud y derechos sexuales y reproductivos y si el hecho de estar expuestas a este tipo de información ayudaba a mejorar sus conocimientos sobre su salud reproductiva y sexual y los derechos conexos. Se organizaron entrevistas semiestructuradas y exhaustivas con nueve mujeres y se examinaron mediante un análisis de contenido cualitativo. Surgieron dos temas: abrir las puertas a nuevos conceptos sobre su salud reproductiva y sexual y los derechos conexos, y plantar la semilla para que participen en cuestiones sobre salud y derechos sexuales y reproductivos, lo que ilustra el modo en que las normas culturales influyen en las percepciones, pero también cómo la información brinda oportunidades para cuestionar estas normas. Tal vez sería beneficioso organizar grupos separados por sexos para que los inmigrantes acepten la información, mientras que podría ser más ventajoso organizar los debates sobre las normas en cuanto a la salud sexual en grupos mixtos.

Keywords:

• Migrants
• sexual and reproductive health and rights
• health education
• health literacy
• Sweden

Introduction

Migration in today’s globalised world is regarded as an enduring rather than temporary condition. In 2014, around 14.4 million persons worldwide had refugee status (UNHCR 2014), and over 620,000 persons applied for asylum in Europe. Sweden received 81,000 applications and had the highest number of applicants in Europe relative to population, with 33,000 asylum seekers being granted refugee or other protective status (Eurostat 2015). Migrants often pose challenges for health systems, necessitating the development of new preventive strategies by the host country (Rechel et al. 2013; WHO 2010). The terms ‘refugees’ and ‘migrants’ are often used interchangeably; however, the forced nature of refugees’ migration involves a more difficult set of circumstances, often comprising experience of violence and conflict, and, for women, experiences of sexual and gender-based violence. Migrants, although a heterogeneous group, generally have poorer health than others (Carballo and Nerurkar 2001; Rechel et al. 2013; WHO 2010). These health inequities are often contributed to by social factors associated with the resettlement process, such as poor living conditions, unemployment and discrimination (Hjern 2012). Importantly, the uptake of health promoting and disease prevention activities is lower among migrants (Rechel et al. 2011). This has been attributed to poorer health literacy. The World Health Organisation defines health literacy as representing the cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand and use health information in ways that promote and maintain good health (WHO 1998). Moreover, health literacy is critical for self-empowerment (Kickbusch 2001). Nutbeam (2000, 2008) conceptualised health literacy as having three dimensions: (1) functional health literacy or the ability to read and understand basic health information in a medical context, (2) interactive health literacy involving communicative skills and maintenance of health in everyday life and (3) critical health literacy, reflecting action taking for own and other people’s health, an awareness of the influence of norms and practices on health and an understanding of social determinants of health. Health literacy is contextual, and migrants may face challenges when confronted with a new language, health culture and health system (Sentell and Braun 2012; Zanchetta and Poureslami 2006). In Sweden, inadequate functional health literacy among migrants has been associated with lower education level, older age and country of origin (Wångdahl et al. 2014). Inadequate functional health literacy may be particularly prevalent among refugees from cultures that radically differ from the resettlement country (Malmusi, Borrell, and Benach 2010).

Barriers to sexual and reproductive health among migrants

Universal access to sexual and reproductive health and rights was underlined in the Cairo Declaration on Population and Development in 1994, which called for policies and programmes to promote gender equity, women’s empowerment and the special needs of female migrants and refugees. One aim was to ensure that individuals could make informed choices regarding their sexual lives (ICPD 1995). Migrant women have higher risk of poor sexual and reproductive health, such as sexually transmitted infections (STIs), unwanted pregnancies or pregnancy complications, compared to the native population in various resettlement countries in Europe. This has been attributed to language difficulties, lack of health system knowledge, limited knowledge about contraceptives and costs of services (Carballo and Nerurkar 2001; ECDC 2014). In many cultures and migrant communities, sexual health is associated with shame and taboo. It is especially sensitive to discuss sexuality and related issues in the presence of men. This restricts access to information and services and leaves room for misconceptions (Hach 2012; Janssens et al. 2006; McMichael and Gifford 2010). In Sweden, low sexual and reproductive health knowledge among newly arrived Iraqi refugees has been explained by limited or absence of education in the home country or disrupted schooling caused by migration, especially among young women (Flodström 2011).

The role of culturally sensitive health education in enhancing health literacy

Culture is a complex concept involving self-identification through many dimensions, such as ethnic identity, traditions, education, gender, economy, religion and language. Culture influences the way we perceive, interpret and act upon health promoting activities (Andrulis and Brach 2007; Rechel et al. 2011). Several strategies can be used to integrate cultural aspects into the design and implementation of health interventions. One strategy is to build cultural competence among health professionals in order to improve communication with culturally diverse populations. Cultural competence in this sense implies an understanding of cultural differences in perceptions of health and behaviour (Rechel et al. 2011). Applying culturally sensitive approaches to health education can improve people’s access to information and possibilities to enhance health literacy. For example, approaches addressing language and an understanding of sociocultural conceptualisations can create a sense of togetherness that facilitates the uptake of a health message, which can be further enhanced if the population of interest can identify themselves with the educator (Kreuter et al. 2003; Saint-Jacques 2012). In relation to migrants, it is essential to acknowledge the impact of the migration process on health (Zou and Parry 2012). Indeed, Khoei and Richters (2008) found that efforts to deliver sexual and reproductive health information to migrant women in Australia failed when sexual health education was delivered by native born Australians without recognition of the sociocultural meanings of sexual health concepts (McMichael and Gifford 2010).

Health education to newly arrived refugees in Skåne

Since 2010 (SOU 2010, 197), newly arrived refugees in Sweden have been offered an introduction programme, including Swedish language training, labour market training and civic orientation (SOU 2010, 16). Participation is obligatory for individuals receiving financial support from the Swedish state. Sixty hours of civic orientation including basic information about the healthcare system are provided in the participant’s first language. Health education is not mandatory. However, in Skåne (i.e. the south of Sweden) an extended programme including health education has been initiated by the county administrative board in collaboration with stakeholders on the local and regional level. The programme is delivered by civic and health communicators and has a focus on participation and dialogue as part of the learning process. The programme builds on culturally sensitive approaches based on a common language, cultural competence among the communicators and recognition of the impact of the migration process on health. Civic and health communicators are themselves refugees and have a background within social science, education or healthcare. They are given a three-week training programme, with information on sexual and reproductive health and rights included since 2012 through a project entitled HIV/STI-Prevention with a Migrant Perspective. Education about sexual and reproductive health and rights encompasses three areas: women’s health, men’s health and HIV/STIs. It includes physical aspects, such as bodily functions and means of STI transmission, as well as psychosocial perspectives involving norms and values in relation to sexual health. In the various language groups, differences between that culture and the Swedish sexual health culture are discussed, and the civic and health communicators adjust the information to the needs and abilities within the groups. The programme is delivered to groups who have a shared language but are mixed regarding gender, age and educational background (County Administrative Board 2012, 2013). In Sweden, children and young people receive comprehensive sexual and reproductive health and rights education in school, and the topic is generally openly discussed (SNAE 2014).

Despite the recognised impact health literacy has on health, few qualitative studies have investigated health literacy as a possible outcome of health education, and culturally sensitive approaches have seldom been explored in relation to health literacy among migrants. The aim of this study therefore was to explore the experiences of newly arrived refugee women with regard to exposure to the health education in sexual and reproductive health and rights provided by civic and health communicators, thereby contributing to deeper understanding of how exposure to such health education could contribute to sexual and reproductive health and rights literacy. Women were targeted due to their particular vulnerability in the migration process and exposure to risks for their sexual health and wellbeing (Janssens et al. 2006) and their gatekeeping role for family health (Skolnik 2008). The study was informed by Nutbeam’s (2000, 2008) conceptualisation of health literacy.

Methods

Research design

A qualitative approach was used to gain a deep understanding of how education concerning sexual and reproductive health and rights was perceived by female participants. This method allowed for an exploration of the meanings of the information in women’s everyday lives and the potential contribution of exposure to such information to enhanced sexual and reproductive health and rights literacy.

Study setting

In 2011, Skåne county received 881 refugees of 18 years or older, most of whom came from Afghanistan, Iraq, Somalia and Iran (Swedish Migration Agency 2012). This study took place in the cities of Lund, Helsingborg and Kristianstad, where 750 newly arrived refugees received information during 2012.

Participants

A purposive sampling strategy was utilised (Dahlgren, Emmelin, and Winkvist 2007) with the aim of reaching women of varying characteristics but similarities with regards to refugee status and having been provided with sexual and reproductive health and rights information by civic and health communicators. Participants were selected from a study population of newly arrived refugee women taking part in health education. The study intentionally targeted women from the three largest refugee language groups at that time, Dari (spoken by people from Afghanistan and Iran), Arabic and Somali, in order to provide a heterogeneous sample. The communicators in the Arabic and Dari groups consisted of three and two men, respectively. In the Somali groups one male and one female communicator led the classes.

Ethical considerations

The county administrative board of Skåne gave permission to conduct the study. The regional ethical review board in Lund approved the study. All informants provided written informed consent in their native language. The consent form explained the purpose of the study, confirmation of confidentiality and anonymity, and the right to withdraw at any time during the research process. It was explained that participation in the study was voluntary and that informants would not be asked to discuss their own or any of their family members’ personal health (CIOMS 2008).

Interview guide

Semi-structured interviews were used to capture informants’ experiences (Kvale and Brinkmann 2009). An interview guide with four broad topics was developed, allowing for flexibility in the ordering of questions and for follow-up questions (Dahlgren, Emmelin, and Winkvist 2007). The first topic explored the experience of receiving sexual and reproductive health and rights information in light of the informant’s life situation, previous experiences and culture. The other three covered features related to Nutbeam’s (2000, 2008) notions of functional, interactive and critical health literacy and included perception of sexual health knowledge, motivation and reflections in relation to their status as refugees, respectively.

Insights acquired from preceding interviews were incorporated into the ensuing interviews through the use of follow-up questions to explore emerging patterns. Female interpreters (n = 7) with experience in interpreting in healthcare settings were hired. Interpreters were given instructions about how to conduct the interviews and the importance of not losing the intended meaning of the questions and responses. The guide was pre-tested with two Arabic-speaking women for assessment of appropriateness of the questions. Although not formally pre-tested in the other language groups due to administrative constraints, it was read and approved by each interpreter before performing the interviews.

Data collection

Data collection took place in March and April 2013 during a period when the civic orientation and health education programme was ongoing. Each language group followed different schedules over a four-month programme consisting of one block per month. The sexual and reproductive health and rights topics were distributed over three blocks, and eligible informants had to finish all three. All eligible informants still enrolled in the programme at the time of data collection were offered the opportunity to participate (n = 19) and were approached by the researcher, with assistance from the civic and health communicators as needed. In classes with more eligible informants, the communicators asked out loud for voluntary participants. The researcher contacted only those who volunteered (n = 3 out of 8). In classes with fewer eligible informants, contact information was collected and the researcher approached them by telephone in easy to understand Swedish or by using an interpreter. When approached, all women were provided with oral and written information about the study in their native language. Two of the eight women who were approached refused to participate (one from the Somali and one from the Arabic group). Of the remaining 17 women, only 9 were interviewed due to time constraints concerning data collection. The interviews took place in the order in which the women completed all sexual health blocks and were scheduled according to individual preferences. Just prior to the interviews, the interpreter provided the women with oral and written information about the purpose of the study purpose and the voluntary and confidential nature of participation. They were informed that the interpreters had signed a confidentiality agreement. Interviews took place in a private setting familiar to the informants. They were audio recorded and transcribed verbatim and lasted between 24 and 48 minutes.

Content analysis

Content analysis of responses was performed using the procedure suggested by Graneheim and Lundman (2004). The transcripts were of sufficient quality such that both a manifest and latent analysis could be performed in the nine complete interviews. Transcripts were analysed separately and bracketed into meaning units. Each meaning unit was condensed and labelled with codes and clustered into content areas: cultural influences on perception, influences of context, the role of civic and health communicators, new insights and health literacy. The software programme Open Code (ICT 2009) was used to facilitate the coding process and to manage content areas, while bracketing into meaning units, condensing and the development of themes was completed manually. Sub-themes and themes were developed after the last interview had been performed (Graneheim and Lundman 2004).

Findings

The final sample consisted of nine women. Four participated in the Arabic language group, three in the Dari and two in the Somali. Their ages ranged between 24 and 38 years. Basic, medium and higher educational levels were equally distributed. A majority of the women were Muslim (see Table 1).

Table 1. Sociodemographic information of the informants in the Arabic, Dari and Somali language groups.

	Arabic (n = 4)	Dari (n = 3)	Somali (n = 2)
Age, years	24–38	24–27	20–25
Length of time in Sweden, months	4, 8, 15 and 16	5, 6 and 8	7 and 8
Education*	Basic (n = 1)	Basic (n = 1)	Basic (n = 2)
	Higher (n = 3)	Medium (n = 2)
Maried	Yes (n = 2)	No (n = 3)	Yes (n = 1)
	No (n = 2)		No (n = 1)
Country of origin**	Syria (n = 2)	Iran (n = 2)	Somalia (n = 1)
	Jordan (n = 1)	Afghanistan/Iran* (n = 1)	Somalia/Syria*
	Iraq (n = 1)		(n = 1)
Religion	Christian (n = 2)	Muslim (n = 3)	Muslim (n = 2)
	Muslim (n = 2)

Notes:

* Basic = ≤9 years, Medium = ≤ 12 years, Higher = ≥15 years

** Birth country/other country where the informant lived for a significant time.

The codes represented different aspects of the experience of receiving health education in sexual and reproductive health and rights by civic and health communicators, the influence of previous experiences, social position and circumstances connected to resettlement. The first overall theme, opening the door to new understandings of sexual and reproductive health and rights, reflects informants’ experiences of encountering a different health culture regarding sexual health. The second theme, planting the seed for engagement in sexual and reproductive health and rights issues, reveals the impact on their everyday lives of having access to previously unavailable information.

Opening the door to new understandings of sexual and reproductive health and rights

Access to previously unavailable sexual and reproductive health and rights information

Migrating to a new country entailed new obstacles to overcome, including communication difficulties, practical concerns and learning to navigate a new health system. This had implications for informants’ strategies for finding information. Women’s social network, primarily friends, had been a source of sexual health information in the home country but, due to migration, these networks were restricted or no longer existed. Irrespective of language difficulties, access to sexual health information was perceived as easier in Sweden as opposed to in their home country, where it was regarded as a very sensitive topic:

Here you get direct information; you can [actually] say that the information comes to you. There [at home] you have to wait, there is an age limit and things like that, and you have to look for this information. (IP2,¹, Arabic group)

This is really a country of information and I have learned so much more here. In the home country it was more for women who had children or who were pregnant. (IP7, Dari group)

The civic and health communicators were perceived as a link to the new country and a source of information, for example about the health system. The Internet was another well-used source, and women often searched out more information from web pages provided in their native language to which they had been referred by the communicators:

It was good … for knowing what to do when you get sick here and for knowing how the health system works, because it is different here than in the home country. (IP6, Arabic group)

You get addresses for websites after the lecture and then, afterwards, I look at it at home, I go to the website and investigate more. (IP5, Dari group)

Sexual and reproductive health and rights information coloured by own norms and traditions

Shame and taboos were, according to the informants, closely associated with sexual health. This hindered them from accessing information in their home countries. While some women had received basic sexual and reproductive health education, for others most of the information was completely new. The knowledge gaps that emerged as a result of the inability to speak openly about sexual health issues had given rise to misconceptions, and there was uncertainty regarding the correctness of the knowledge they had received previously. Information was perceived as more accurate in Sweden and was welcomed for challenging misconceptions, for example, regarding STI/HIV transmission and the safety of condom use:

… that it is not safe … it is not one hundred percent … there is always a risk that the women will get pregnant even if you use a condom … they say that at all condoms have a hole in it so it will leak … (IP3, Arabic group)

One time he [the communicator] brought condoms and it was free … but no one took any because it was embarrassing. If I had a man I would have taken many, I had never seen what one looks like before. (IP4, Arabic group)

The rights aspect of sexual and reproductive health, such as the right to family planning and the notion that persons with HIV have rights, was also new for the women. They expressed the view that access to contraceptives was easier in Sweden compared to in their home countries. Mention of rights had been missing from the education they had received in refugee camps. Moreover, most women came from cultures that heavily stigmatised persons with HIV and which did not acknowledge their rights:

… that here in Sweden you are a person, and you can live with AIDS, he will get medication, and he will get help, he will get the right information … you can also not infect others. This is a big difference … in the home country if someone has this disease you run, no one greets him, no one talks to him, no one sees him, he becomes very isolated. (IP8, Somali group)

Women’s initiation of discussion regarding the influence of their own cultural norms on perceptions of sexual and reproductive health and rights information and the approach used by the civic and health communicators indicated an increasing awareness of different points of view. They realised the need for such understanding when discussing these topics in mixed groups (e.g. by gender, age and education level):

The problem is not the information, but it is the people, and the persons that listen to it. They are shy and it is embarrassing to listen to this kind of things [sexual health information] in our home country. (IP4, Arabic group)

Women revealed that mixed groups limited their access to information. Norms of shame and taboo were reinforced in the classroom, and informants felt tensions both within the group and between the communicator and the group. The women perceived that the communicators adjusted the information to accommodate persons who appeared to be uncomfortable. Thus, when the communicators raised sensitive issues related to sexual health in groups composed of people originating from cultures where such matters were not openly discussed, the information provided was felt to be filtered or restricted. Although new knowledge was introduced, cultural barriers affected the content and constrained the transfer as well as the uptake of information. This feeling was particularly acute when there was a male communicator:

Since it is taboo in the home country, and here as well, it is the same people that are here in the classroom, I still think that it was not completely open information. (IP1, Dari group)

Questioning the approach to delivering information

The information provided by the civic and health communicators was both desired and appreciated by the women. However, due to group composition, they perceived that opportunities for discussion were limited, leaving many questions unanswered. They suggested that a gender-sensitive approach may have been more suitable for the subject matter:

But because it was a male … and it was mixed with men, then you get information but you would like to also ask questions, and want answers to the questions, but you never get it, you can′t do it [ask questions]. (IP3, Arabic group)

I think that it should have been a group with only women and a woman who informed us, it would have been easier both regarding women’s health and men’s health. (IP1, Dari group)

Women noted that the mixed groups also created challenges for the communicators. They recognised the need for the communicators to achieve a balance regarding diversity in terms of knowledge levels as well as degree of acceptance of the information delivery approach, within the group. Some women may have perceived that the information was being forced upon them:

It was fantastic information, it was very easy to grasp and at the same time he was so careful not to cross the border. I think for me it was pretty good, I felt comfortable, but there were others who did not feel comfortable. (IP6, Arabic group)

If it is someone from the same country, it should be a female … or a man who speaks Swedish … then the person might not have the same way of thinking, if he is not from the same culture … maybe it would have been easier for that person [the communicator]. I noticed that he did not want to talk about it because of the older women. (IP7, Dari group).

Viewing the civic and health communicators as sources of important information

Although the information received was perceived as sensitive, women stressed the importance of receiving accurate information, and civic and health communicators were perceived as a reliable source of supply. Informants reported that their level of sexual and reproductive health and rights knowledge increased to various degrees and expressed a desire for more information. They stressed how this knowledge would be useful for future needs, either for themselves or someone in their family:

In the future, if something happens, within the family, then you are informed. (IP6, Arabic group)

It is important for every woman to be informed about this, if you will have a family, or have contact with someone. (IP1, Dari group)

Communicating sexual and reproductive health and rights information using culturally competent communicators having an understanding of both Swedish and traditional cultural perspectives within the groups facilitated the transfer and uptake of information. Pictures, videos and other teaching methods stimulated interaction in the groups. Although not all women felt comfortable participating, discussions between group members were seen as benefitting those with less confidence:

It was through the discussions, because it was a man who instructed this … but we never participated in the discussions because it was a sensitive topic, but you got a lot of information … especially when they draw on the board, and when they showed pictures through the computer and things like that … then we received a lot of information, but we could not communicate with the others, because it was very sensitive and we were very shy. (IP3, Arabic group)

Planting the seed for engagement in sexual and reproductive health and rights issues

Information from civic and health communicators provided new perspectives

In addition to the new knowledge acquired, women felt that the information actually changed their lives. Knowledge gained, as well as the way of delivering information in groups with women and men together had been an eye-opener and contributed to new ways of relating to sexual and reproductive health. This had produced positive change in some participants’ everyday lives. For example, it had introduced new ways of communicating with husbands and other family members without feeling embarrassed:

Before, I could never mention in front of my husband that I had my period, but now after I have learned that it is a normal thing, that you can talk about it, so now when I have my period I go and tell my husband about it, and this information has led to something positive for me. (IP3, Arabic group)

Access to sexual and reproductive health and rights information appeared to go beyond the mere practical aspects, enhancing women’s self-confidence and motivating them to learn more:

… now I have started to feel that I am very brave because I dare and I can receive information and … so with time I think that I will be even more brave, and have more information, and dare. (IP3, Arabic group)

Before I came here and participated in this course I had little information, but now I have a lot more and I feel now that I can manage anything, anytime, plus that I have the will to learn more and more and more. (IP4, Arabic group)

Questioning restricted access to important information

The women recognised the need to adapt to new health norms. Although they were unaccustomed to discussing questions openly, they could see the value of normalising the subject, while at the same time realising that these changes could take time. The importance of sexual and reproductive health and rights information for all newly arrived refugees, both women and men, was emphasised, as people from their home countries usually lacked this knowledge. Such knowledge was central tor the ability to take care of their own health and that of others:

I have got so much information now, and I have become so positively impressed at the same time as I have all this new knowledge and information. We get so much new knowledge, they [refugee women] don′t know anything, they don′t know anything about what a good health is, nothing, a woman know before giving birth and after have given birth, that’s it. You have to get new knowledge, and this is new knowledge for these women, because they have never talked about it before, they don′t know what it means. (IP3, Arabic group)

The importance of sexual and reproductive health and rights knowledge for newly arrived refugees was further illustrated when the women started to question the cultural norms and traditions that had hitherto hindered their access to information, both in their respective home countries and to a certain degree also in Sweden. An alternative way of perceiving the mixed-sex groups and the male communicator was voiced. Rather than perceiving the group’s composition as restricting information, it was viewed as opening up new ways of thinking about gender norms. Women argued that people in their home country needed to get used to the new culture and reframe their traditional understandings of sexual health in particular, and gender norms in general:

Here I feel that the wall is falling. That the women are sitting together with men and receive the same information, it doesn′t occur often in our countries, so this was the best part. (IP2, Arabic group)

There it was better [with a female teacher] … considering the culture and the women … so in that way it was good, it was appropriate, but here I think it was good and positive that it was a male teacher because you get used to it, the women get used to it, that it is normal and that everyone talks about it. (IP7, Dari group)

It is an important subject, for both men and women, because you need to take care of yourself … and even be able to change your cultural opinions, to something more positive, that you can use here in Sweden. The main thing is that you should be able to take care of your health … that’s the main thing. (IP6 Arabic group)

Expressing the wish to spread new knowledge to significant others

Growing awareness of the urgency to disseminate sexual and reproductive health and rights information to other newcomers contributed to a sense of wanting to reach out, and gained confidence contributed to a perceived ability to actually teach others. Some women described how they had forwarded the information they had received through the groups to friends and other family members. A desire to share knowledge with others outside their social network was also voiced:

I would like to start to educate others about what it means, right now I have a friend and her husband works, and she only attends SFI [Swedish For Immigrants], and have not received this information, and every time I have learned something new I go to my friend and we sit down and talk about this, and I tell her that this is the symptom for this or this disease, and this and that, and I can inform about this. (IP3, Arabic group)

I have discussed a lot with my husband about this at home, it has been very interesting for me. I even consider the possibility of educating the new generation about this, so that they will get better knowledge and better information, and it is my next step to actually consider this. (IP6, Arabic group)

Discussion

This was the first study in Sweden to explore refugee women’s perceptions of receiving sexual and reproductive health and rights information from civic and health communicators and its contribution to health literacy. Findings point to two themes that highlight the complex interplay of factors that enable or constrain information uptake: (1) opening the door to new understandings of sexual and reproductive health and rights and (2) planting the seed for engagement in sexual and reproductive health and rights issues. Findings suggest that women’s initial perceptions of sexual health and rights issues were deeply influenced by cultural norms and gender structures, internalised in feelings of shame and taboo. They also show that the approach by which information was delivered, in groups with men and women together, stimulated critical reflection regarding cultural sexual health norms as well as gender norms in general.

No formal assessments of health literacy outcomes were conducted as part of this study; instead, health literacy achievement was assessed through women’s descriptions of knowledge gains and shifts in attitudes, in line with other qualitative studies (Renkert and Nutbeam 2001). Women indicated that they saw themselves as better informed and more confident in using the gained understandings after having received the information. Restricted sexual health education in the home countries and disrupted schooling due to migration had resulted in limited sexual health literacy, where sexual health was primarily viewed as concerning HIV transmission and reproduction, omitting other sexual health and rights aspects (see also Flodström 2011; McMichael and Gifford 2010). This was especially evident among women who had spent longer in transit. Information delivered by civic and health communicators introduced new topics and opened up new perspectives, which were welcomed for challenging traditional views and for filling knowledge gaps.

With regards to interactive health literacy (Nutbeam 2000, 2008), sexual and reproductive health and rights information moved beyond factual knowledge gains to influence attitudes and ways of relating to these issues. Findings indicate that enhanced confidence contributed to new ways of communicating about sexual health issues with partners, friends and children, highlighting the social aspects of health literacy as a part of everyday life and that the barriers between men and women were to some extent removed. Women showed an awareness of culturally different sexual health norms and the need for adaptation in order to ensure health. This was manifested in the way they questioned traditional gender norms and perceived them as constraining their possibilities to achieve optimal sexual health. At the same time, some ambivalence remained. Women needed time to internalise their new understandings of sexual and reproductive health and rights – a topic that is deeply stigmatised and that cannot be discussed without considering gender inequity and power (Janssens et al. 2006; Malmusi, Borrell, and Benach 2010). Recognition of the importance of sexual and reproductive health and rights literacy among newly arrived women indicated an awareness of how they as women, and especially as migrants, needed to be equipped with knowledge in order to take control of their health, in line with WHO’s (1998) notions of health literacy and the critical dimension of health literacy (Nutbeam 2000, 2008). Women’s awareness of the rights aspect of sexual and reproductive health indicated an increased sense of empowerment, especially with regard to the right to family planning (ICDP 1995).

Faced with a new context and culture with reduced support from their usual social network, civic and health communicators were seen as a significant link to the new country (Flodström 2011), bridging the gap between two contexts (home country/resettlement country). Group dynamics contributed to a sense of cohesion in which commonalities in language, background and the experience of being new in Sweden created a forum for sharing perspectives. Women stressed the participatory approach had been beneficial for learning, yet in relation to the sensitive topic of sexual health, open discussion was limited. The value of delivering such information in mixed groups in this context was questioned. Feeling vulnerable as women and refugees may contribute to the perception that the adoption of certain norms is expected (Papen 2009). In one sense, mixed groups were perceived as reinforcing cultural barriers and a shared sense of the shame and taboo associated with sexual health distorted communication. On the other hand, mixed-sex groups were seen as a way of challenging cultural gender norms. This ambivalence – regarding the need for a shift in cultural attitudes, while at the same time stressing the importance of cultural sensitivity for ensuring access to information – was also seen in Rogers and Earnest’s (2015) study. Our findings suggest that basic information on sexual and reproductive health and rights is perhaps best delivered in same-sex groups to ensure its uptake by persons with limited knowledge, while critical reflection on norms and values may benefit from being discussed in mixed-sex groups.

Methodological considerations

This study has several limitations that need to be mentioned. Firstly, using an interpreter can constrain the flow of conversation, limiting access to tacit knowledge and trust (Dahlgren, Emmelin, and Winkvist 2007). Only professional interpreters were hired in this study, but their experiences varied, and although efforts were made to overcome linguistic obstacles, some intended meanings may have been lost in translation. Using semi-structured questions facilitated interpretation, but a pre-determined health literacy framework may involuntarily prompt certain kinds of answers. However, the interview guide was mainly used as a support and women were encouraged to reflect freely on their experiences. The fact that both interpreter and researcher were probably of the same gender is likely to have contributed to a more comfortable situation (Kvale and Brinkmann 2009).

Considerable effort was made to ensure that informants understood that researcher was separate from the civic and health communicators. Nevertheless, participants may have felt that their answers could harm the communicators’ work, affecting their willingness to report negative experiences. Although all eligible women were offered the opportunity to participate, women with more positive experiences may have preferentially been included, since they may have shown a greater interest in participating. As the final sample largely represented the experiences of younger women, the findings may have failed to capture variations based on age. Older women may have more conservative views and lower education levels.

Interviews varied in length, which may have posed limitations regarding the richness of the data obtained. Also, the time available for data collection was limited, resulting in small sample size. Nevertheless, the findings reveal both positive and negative perspectives, representing the voices of women with different experiences but similar reflections. Data collection moved towards saturation, as the interviews confirmed what had emerged from preceding interviews; however, additional interviews may have revealed new information, leading to a different results. That said, the findings do show similarities with those of other studies with regards to views on culturally sensitive sexual and reproductive health education (Flodström 2011; McMichael and Gifford 2010; Rogers and Earnest 2015).

Finally, while this qualitative study contributes to a deeper understanding of refugee women’s perceptions of knowledge gains, more formal assessments are required to measure changes in health literacy.

Conclusion

Culturally sensitive health education provided by civic and health communicators facilitated the transfer of sexual and reproductive health and rights information to newly arrived refugee women, but cultural barriers created restrictions for information access. Sexual and reproductive health and rights literacy, in addition to being crucial for migrants’ health, may also facilitate their acculturation into the new society. Further studies are needed, however, to examine the relationship between sexual and reproductive health and rights literacy and acculturation among migrants in Sweden and to design and develop health interventions directed towards recent arrivals and other vulnerable groups.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes

1. The acronym IP here refers to the interviewee or ‘interviewed person’, and the number provides a unique identifier for each informant in this study.