Education for sexual and reproductive health and rights (SRHR): a mapping of SRHR-related content in higher education in health care, police, law and social work in Sweden

ABSTRACT

Knowledge of sexual and reproductive health and rights (SRHR) by health care, police, legal and social work professionals has been shown to be insufficient. This lack of competence is likely to affect the quality of services. The aim of this study was to describe SRHR indicators in educational programmes in health care, police, legal and social work higher education in Sweden. A text-based analysis was conducted of written material from all educational programmes in law, midwifery, nursing, occupational therapy, physiotherapy, police work, psychology, social work and undergraduate medicine (93 educational programmes at 27 universities and university colleges). Representation of different SRHR indicators varied, but most were poorly covered in the educational programmes. Existing educational programmes lack comprehensiveness in their coverage of SRHR and are unequal both within and between the professions and universities. This situation creates the risk of inequalities in SRHR competence and suggests that needs within this field may be unmet. There is an urgent need therefore to enhance the presence of SRHR in health care, social work and law enforcement education in Sweden.

KEYWORDS:

• Sexual and reproductive health and rights
• education
• health care
• legal work
• police work
• social work

Introduction

Concern for Sexual and Reproductive Health and Rights (SRHR) is essential for sustainable health development because of their links to gender equality and well-being, their impact on health through the lifespan, and for their role in shaping future economic development and environmental sustainability (Ghebreyesus and Kanem 2018; Starrs et al. 2018).

In high income countries such as Sweden, aspects of SRHR have proved to be important health determinants, not least because they have strong a connection to non-communicable health issues such as mental ill health and chronic disease (Starrs et al. 2018). Population-based studies in Sweden have shown an increase in sexually transmitted infections (STI) and high prevalence data of sexual violence (Danielsson et al. 2012), stressing the importance of professionals in health care, the police, legal and social work being competent in SRHR.

To ensure SRHR for all, it is important to involve a range of actors, sectors and policies to address SRHR via cross-sectoral work (Ghebreyesus and Kanem 2018). Progress in SRHR requires confronting the barriers embedded in laws, policies and social norms and values – especially gender inequality – that prevent people from achieving sexual and reproductive health. Hence, professionals working in health care, police, legal and social work are key actors in achieving improved sexual and reproductive health and safeguarding sexual and reproductive rights. Addressing these issues is a matter of concern in all countries but also for international agencies and organisations. The United Nations (UN) Agenda 2030 for sustainable development, for example, clearly outlines the importance of more integrated and comprehensive work on SRHR (United Nations 2018).

The UN Sustainable Development Goal (SDG) 3 (healthy lives and well-being), target 3.7 indicates that member states should ‘ensure universal access to sexual and reproductive health care services, including family planning, information and education, and the integration of reproductive health into national strategies and programmes’ (World Health Organization 2016). Goal 5 (gender equality), target 5.6 states that all member countries should ‘eliminate all forms of violence against all women and girls in the public and private spheres, including trafficking, sexual and other types of exploitation’. The proposed roadmap to fulfilling these goals involves avoiding the overly sharp boundaries of the former millennium development goals and, instead, integrating and synergising efforts across sectors. The WHO European Action Plan, developed as a response to the SDGs, includes several actions, one of which is ‘incorporating sexual and reproductive health and rights education into the curricula for all relevant educational and health service personnel and social workers’ (World Health Organization 2016).

Even though the Action Plan and the SDGs are not legally binding, national governments are expected to take ownership of them and establish frameworks for implementation and monitoring. The Government of Sweden has developed an action plan for the implementation of the SDG agenda, declaring Sweden’s commitment to an integrated monitoring framework for the coming years (Government of Sweden 2018). The action plan will require data collection not only within the field of epidemiology but also within health systems, social and legal services, as well as in education. It is crucial that higher education is part of the dissemination of knowledge in the field of SRHR. However, evaluating how SRHR is addressed in higher education in health care, police, legal and social work in Sweden is complex since it involves reviewing not only written curricula, but also issues of pedagogical practice and a holistic understanding of SRHR (among both students and lecturers) as it informs students´ future professional practice.

In studies from Europe and North America, knowledge of different aspects of sexual health, sexuality and SRHR has been shown to be insufficient among students and professionals in nursing, occupational therapy, physiotherapy and social work. Students and professionals report inadequate training and clients/patients describe their experience of meeting professionals in contexts where lack of competence in SRHR is revealed (Aaberg 2016; Areskoug-Josefsson and Fristedt 2017; Areskoug-Josefsson and Gard 2015; Areskoug-Josefsson et al. 2016; Blakey and Aveyard 2017; Dunk 2007; Logie, Bogo, and Katz 2015; Papaharitou et al. 2008; Saunamaki and Engstrom 2014; Schaub, Willis, and Dunk-West 2017; Winter et al. 2016).

A common denominator in higher education programmes in health care, police, legal and social work in Sweden is that they prepare the student to work independently, since as a qualified professional they will encounter individuals across a various of ife situations. Professionals´ lack of competence in SRHR will likely affect the quality of services they provide, and the needs of clients/patients regarding SRHR may be insufficiently met. Additionally, the different expectations of clients/patients, employers and society may be difficult for the untrained professional to reconcile. Student attitudes towards SRHR are strongly influenced by culture and affect how learners regard their professional role in regard to the promotion of SRHR (Bhavsar and Bhugra 2013). Culture plays a role in defining what is considered normal, what is seen as abnormal, and the underlying factors behind these assumptions (Atallah et al. 2016; Bhavsar and Bhugra 2013). To have a positive effect on health outcomes for the individual and the population, it is important that the curriculum is well designed (Frenk et al. 2010), making it possible to achieve the competencies needed for work related to SRHR (Winter et al. 2016).

However, to date there has been insufficient research regarding to what extent and with what focus educational programmes in health care, police, legal and social work should take regarding SRHR in Sweden. Research is needed to clarify both to what extent SRHR, and which specific aspects of SRHR should be included or excluded in higher education for these different professions.

Aim

Against this background, this study aimed to describe the extent to which SRHR indicators were present in nine different professional higher educational programmes: law, midwifery, nursing, occupational therapy, physiotherapy, police work, psychology, social work and undergraduate medicine in Sweden.

Materials and methods

The study took the form of text-based analysis of written materials from all educational programmes in law, midwifery, nursing, occupational therapy, physiotherapy, police work, psychology, social and undergraduate medicine work in Sweden. In higher vocational education at Swedish universities and university colleges, content and requirements are regulated by the Swedish Higher Education Act (Swedisch Council for Higher Education 2018). The interpretation and management of these requirements can (and does) vary, but all are audited regularly via national quality assurance processes.

The study was conducted in 2016 and included 93 educational programmes at 27 universities, including university colleges (Table 1). One midwifery programme and two nursing programmes did not agree to have their course syllabi examined and are therefore not included in the study.

Table 1. Number of educational programmes and length of educational programmes.

Profession	Length of educational programme	Number of educational programmes included in the study
Lawyer	4.5 years	6
Midwife	3 years (nursing programme) + 1.5 years (midwife programme)	13
Nurse	3 years	24
Occupational therapist	3 years	8
Physician	5.5 years	7
Physiotherapist	3 years	8
Police	2.5 years	3
Psychologist	5 years	10
Social worker	3.5 years	14

The study protocol consisted of the following steps.

1. Development of SRHR indicators via a narrative literature review, the formation of a reference group and consensus agreement on indicators to be included, by both the research team and the reference group.

2. Data collection via documentation on each profession, programme descriptions and course syllabi from each included programme.

3. The pilot testing of indicators via a manual search of indicators in documentation from one educational programme for each profession, from different universities. The manual search for indicators was performed using representational interpretation (Roberts 2000). Identifiable indicators and the indirect presence of indicators (for example when synonyms for various indicators were used) were counted for each document.

4. The presentation of pilot results to the project reference group by e-mail for feedback, to enable the revision of the chosen indicators and to ensure a fuller understanding of indirect indicators.

5. The revision of indicators, including adding one indicator and rephrasing some of the indicators, to produce a definitive version of indicators

6. A manual search for indicators in all collected documents from all included educational programmes by reading, highlighting indicators and the use of representational interpretation. Identified indicators and evidence of the indirect presence of indicators were counted for each document.

7. Analysis of results and presentation of preliminary results to the reference group by e-mail for feedback.

8. Preparation of a national report on the results.

The SRHR indicators identified and used in this study are listed in Table 2 below.

Table 2. SRHR indicators.

Andrology

Asexuality

Communication

Contraception

Discrimination

Ethics

Gender

Gynaecology

Harm reduction in SRHR

Hetero norm

Honour-related violence

Individual, social and cultural norms

LGBTQ

Mental health/illness

Obstetrics

Pornography

Risk exposure and risk taking

Selling and buying sex

Sex against one´s consent

Sexual Diseases Act

Sexual medical history

Sexual problems/disorders

Sexual well-being/pleasure

Sexual violence

Sexuality and disability

Sexuality as a social construction

Sexuality through the lifespan

SRHR (general)

STI/HIV

Trafficking/exploitation

Women´s health

Findings

Overall, SRHR was insufficiently addressed in the investigated 1,560 written documents (in terms of the description of the profession, programme descriptions and course syllabi for each included programme). The following account reveals the extent to which evidence of the SRHR indicators was present in the collected data from the three types of document.

SRHR in profession descriptions

All profession descriptions for midwifery and occupational therapy had SRHR indicators present. Fewer SRHR indicators were present in the other professional descriptions – 70% of psychology descriptions, 50% of social work descriptions, 33% of police work descriptions, 29% of undergraduate physician descriptions, 28% of nursing descriptions and 17% of legal work descriptions. In documentation describing physiotherapy no mention of SRHR was found.

SRHR in programme descriptions

The programme descriptions of all midwifery, police, psychology, social work and undergraduate medicine programmes included SRHR indicators. Only one of the 25 nursing programmes lacked SRHR indicators. Among legal programmes two of the six programmes examined did not include any SRHR indicators. In the rehabilitative professions, two of eight physiotherapy programmes and four of the eight occupational therapy programmes lacked SRHR indicators.

SRHR in course syllabi

The nine different educational programmes examined varied in number of courses per semester (1–6) both between professions and between universities. This was the case even when the length of the educational offering and the stipulated learning outcomes were the same.

Before reporting on the presence of SRHR indicators, some caveats are needed. Some programmes had a higher number of courses than others, which may have led to the indicator appearing more frequently in a programme with many courses. Additionally, the number of educational programmes available for each profession had an impact on the amount of indicators represented, as a higher number of educational programmes could lead to a larger representation of often used indicators in course syllabi (Table 3). The syllabi for courses also varied in quality and length of text, which may have affected how the indicators appeared in the investigated material.

Table 3. Number of indicators present in course syllabus for each profession.

	Lawyer	Midwife	Nurse	Occupational therapist	Physician	Physiotherapist	Police	Psychologist	Social Worker
Andrology		9	7		8
Asexuality
Communication	2	39	108	23	60	29	6	49	50
Contraception		27	2		1
Discrimination	1			1	1	1	4	3	11
Ethics	5	71	192	49	78	43	11	64	117
Gender	13	31	94	18	29	23	6	49	58
Gynaecology		38	20		13
Harm reduction in SRHR
Heteronorms							1	2	1
Honour-related violence							1
Individual, social and cultural norms		6	5					7	12
LGBTQ	2	7	1	1	4		2	3	7
Mental health/illness		12	38	27	19	12	3	91
Obstetrics		64	11		13
Pornography		1					1		1
Risk exposure and risk taking		4	1		1		2	1	1
Selling and buying sex							1		1
Sex against one´s consent		1	1				1	2
Sexual Diseases Act		4	3		3				1
Sexual medical history		6			2			1
Sexual problems/disorders		4			5			2
Sexual well-being/pleasure
Sexual violence		10	2		2		3		1
Sexuality and disability		1
Sexuality as a social construction		1				1		2	3
Sexuality through the lifespan		17						3	1
SRHR (general)		93	20	1	18	1		1	28
STI/HIV		15	5		7
Trafficking/exploitation							1		1
Women´s health		65	8		2	1

The representation of the SRHR indicators in the course syllabus for each form of professional education varied, and the indicators ethics, gender and communication were the most frequent among all professions. Most of the other investigated indicators were poorly covered in the educational programmes and the following indicators were not present in any course syllabus: harm reduction in SRHR, sexual well-being/pleasure, and asexuality. Sexuality and disability was only present in one course syllabus (in one midwifery programme) and honour-related violence was only present in one course syllabus (in one police work programme).

Both occupational therapy and physiotherapy syllabi had a very low representation of SRHR indicators, indicating that the rehabilitative programmes have a low and insufficient coverage of issues relevant to sexual and reproductive health and rights.

Police education programmes had a broader coverage of SRHR indicators than legal educational programmes. For example, in the legal course syllabi only the following indicators were present: ethics, gender, communication, discrimination and LGBTQ.

Psychology and social work programmes had low or absent representation of several SRHR indicators and of indicators concerning criminal offences such as sexual violence.

Considering the high number of nursing programmes compared to other programmes, the representation of SRHR indicators was sparse and suggested considerable diversity between nursing programmes regarding SRHR.

Midwifery and undergraduate medicine had more indicators than other professions present in the text material from their educational programmes, but there were important indicators that were not present such as non-consensual sex (rape), honour-related violence, the selling and buying of sex, and heteronormativity.

Overall, results reveal differences within universities. The same university might have educational programmes for one profession with a higher prevalence of SRHR indicators, while the same indicators were absent from other professional programmes. There were also major differences in the extent to which SRHR indicators were present in different professionals’ programmes, as well as within programmes for the same profession. The programme that was most consistent between universities was police education, which may be due to it being offered by only three universities in Sweden.

Discussion

A lack of good quality education in SRHR may lead to lack of professional competence in SRHR, which in the long run may have negative consequences for health and society. There were major differences between the same form of professional education being offered at different universities, but also in SRHR’s presence in different educational programmes at the same university.

The shortcomings of higher education concerning SRHR revealed here may lead to a professional lack of accountability and a failure to meet needs, both individual and societal. Based on what we identified, action needs to be undertaken and universities should use the results to further develop and update the education about SRHR that they provide. The national quality assurance audits, performed by the Swedish Council for Higher Education, could be used to also follow-up in this respect by including important SRHR indicators in the work they do.

Just as importantly, a wide range of future professionals should be given the opportunity to promote and safeguard SRHR for all, since being part of a joint effort to improve SRHR for individuals is a mission for all health and welfare professionals. It is not a task for a single profession (Frenk et al. 2010). One suggestion for strengthening the presence of SRHR in professional education is to increase opportunities for interprofessional learning, both within universities and between similar kinds of professional education. Increased collaboration can also lead to more collaborative and less hierarchical relationships in interprofessional teams (Frenk et al. 2010). Important forms of interprofessional education in sexual health (Coleman et al. 2013; Penwell-Waines et al. 2014) could be developed through increased collaboration, especially in universities offering educational programmes in health care, police, law and social work.

To provide adequate care and support, as well as to protect human rights and advance gender equality, all the professionals in different working areas need to follow evidence and best practice. Curricula should serve as platforms reflecting the evidence-based knowledge in SRHR specific to each field of higher education. This could increase students´ future ability to handle the situations concerning SRHR and contribute to progress towards positive change in both preventive and promotive SRHR work. This in turn may lead to the increased probability of achieving the UN SDGs and WHO Europe’s SRHR Action Plan (United Nations 2018; World Health Organization 2016).

Methodological concerns

A major strength of this study is its broad and inclusive sample. A weakness, however, derives from the fact that we report on a documentary analysis and there may be additional factors influencing students´ actual knowledge, skills and competence in the field of SRHR that have not been investigated. For example, formative experiences, values education and transformative learning were not addressed as part of the study design.

Additionally, during data analysis additional indicators were identified as important in SRHR but which were not included in the list of indicators we looked for, such as genital mutilation. The list of indicators we used also contained few indicators related to the positive aspects of SRHR, and the indicator for sexual well-being was not present in any of the investigated documents. In future research, it will be important to include these more positive aspects of SRHR, especially since they seem less present than other aspects of SRHR in current education offerings.

Conclusion

There is clearly a need to strengthen the inclusion of SRHR in higher education in health care, police, legal and social work education in Sweden so future professionals can act upon the needs and rights of their future clients/patients. Existing educational programmes do not provide comprehensive education about SRHR and there are variations both within and between professions and universities. This lack of education poses the risk of inequalities in SRHR competence, and suggests that needs in this field may be unmet, which in turn poses a health risk, especially for vulnerable populations.

Acknowledgments

The study was funded by the Public Health Agency of Sweden as a component of the National Strategy on HIV/AIDS (Government of Sweden, 2017).

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This work was supported by the Sveriges Regering [The study was funded by the Public Health Agency of Sweden].