Sexual and mental health among young male forced migrants in Stockholm : needs, links, and responses

<p dir="ltr">Background</p><p dir="ltr">For young male youth, forced migration experiences often involves a heightened risk for sexual and mental health challenges as well as poor outcomes due to limited access to services and knowledge gaps. Consequently, they may have specific sexual and mental health needs in the host country that are seldom fully addressed. Much of the current research on sexual and reproductive health and rights primarily focuses on the experiences of women leaving a significant gap in understanding the diverse perceptions and experiences of young male forced migrants, their associated sexual and mental health needs, and how these two domains are interlinked. Additionally, there is a lack of research exploring the perspectives of health care professionals, regarding their experiences and capacity to address these needs, and their experiences of cross- cultural training designed to improve knowledge and quality of care.</p><p dir="ltr">Aim The overarching aim of this thesis is two-fold. The first aim is to gain a deeper understanding of the sexual and mental health needs of young male forced migrants, the connection between these two domains, and how to address these needs from the perspectives of young Eritrean, Syrian, and Afghan men and healthcare professionals in the Stockholm region, Sweden. The second aim is to evaluate Comprehensive Cross- Cultural Training (CCCT) for mental health care professionals about refugees and asylum seekers mental health and care in Stockholm.</p><p dir="ltr">Methods</p><p dir="ltr">Data were gathered from two research projects. The first project comprised three studies (Studies I-III), which employed an exploratory qualitative approach using semi- structured interviews, while the second project (Study IV) applied a concurrent embedded mixed-method research design, combining both quantitative and qualitative data. A total of 32 semi-structured interviews were conducted with young male forced migrants originally from Syria, Eritrea and Afghanistan (aged 16-28 years) between June 2019-October 2020 in the Stockholm region, using theoretical sampling (data used for study I and II). For Study III, nine interviews with healthcare professionals were carried out using snowball sampling. Qualitative data from Study I was analyzed using constructivist grounded theory, while Study II and III employed inductive qualitative content analysis. In Study IV, for the quantitative sub-study, pre-and post- questionnaires were used including 17-items assessing perceived knowledge. The qualitative sub-study comprised six focus group discussions (FGDs). For Study IV, nested sampling was used while heterogeneous purposive sampling was employed for the FGDs. Quantitative data were analyzed using t-tests and factor analysis whereas qualitative data were analyzed using thematic content analysis.</p><p dir="ltr">Results</p><p dir="ltr">In Study I, we found that sexual and mental health needs of young men evolved over time, reflecting an individual process of change, including attitudinal shifts. Across Studies I-III, six key areas of sexual and mental health needs were identified: needs related to recent forced migration experiences, understanding changing norms, navigating romantic and sexual relationships, needs related to knowledge gaps and building skills, the need for and seeking information and healthcare and using services and interacting with healthcare professionals.</p><p dir="ltr">A multitude of factors influenced the process of change and the fulfillment of sexual and mental health needs. Facilitating factors included attending school and receiving sexuality education, support in adapting to the Swedish society, and experiencing enjoyable relationships. Constraining factors involved restrictive parental values, exposure to discrimination and stigma, and negative narratives about young male refugees. Furthermore, in Study II having a supportive female partner was found to facilitate sexual communication, including discussion about safer sexual practices, sexual transmitted infection (STI) status, testing, condom use, and accessing local services. In Study III, sexual and mental healthcare providers emphasized the importance of an integrated approach to care but noted limitations in service provision and in meeting the needs of young men with forced migration experiences. They also highlighted the need for specific training. In Study IV, participants of the cross-cultural training reported enhanced perceived knowledge and new perspectives in relation to the content. From the FGDs, it was revealed that refugee patients were perceived as a challenging group to care for, but the cross-cultural training promoted empathy towards this patient population and strengthened their professional role.</p><p dir="ltr">Conclusions</p><p dir="ltr">This thesis aims to contribute to an extended understanding of sexual and mental health needs of young male forced migrants, how sexual and mental health are interlinked, and potential approaches to address them. It incorporates perspectives from both the young male themselves and health professionals in the Stockholm region, offering a broader view of needs.</p><p dir="ltr">To effectively respond to these needs, it is crucial to first understand their nature, the interconnection of sexual and mental health, the process of change, and influencing factors. While navigating a new social context, young male forced migrants would benefit from ongoing support, guidance, knowledge, and practical skill development related to sexual and mental health. These insights should inform public health and educational interventions targeting youth, as well as healthcare practices, including the training and support of public health and health care professionals. Educational interventions for refugee and asylum-seeking youth groups should consider migration experiences and related challenges, be culturally sensitive and tailored, and integrate both sexual and mental health components.</p><p dir="ltr">In the context of service delivery, sexual and mental health needs, and their interconnection, are not being effectively addressed. This underscores the importance of continuously supporting health professionals, both organizationally and individually, to acquire cross-cultural knowledge, skills, tools, and practices. It also highlights the need to consider forced migration experiences, adopting reflective approaches, and including young men in care decisions, allowing time to build trust.</p><h3>List of scientific papers</h3><p dir="ltr">I. Tewelde McDonald J, Fayzi B, Laktinah M, Ekström AM, Salazar M. 'Sweden has changed me': a qualitative study exploring the sexual health needs and associated mental health aspects of young male former unaccompanied minors, asylum seekers and refugees in Region Stockholm, Sweden. BMJ Open 2024;14:e080514.<br><a href="https://doi.org/10.1136/bmjopen-2023-080514">https://doi.org/10.1136/bmjopen-2023-080514</a><br><br></p><p dir="ltr">II. Tewelde McDonald J, Fayzi B, Laktinah M, Ekström AM, Salazar M. Attitudes, perceived knowledge, experiences and needs regarding condom use, STIs, transactional sex, and sexual healthcare among young male forced migrants in Stockholm, Sweden: a qualitative study [Manuscript]</p><p dir="ltr">III. Karimah F, Tewelde McDonald J, Stålgren M, Salazar M. Healthcare providers' perceptions of mental and sexual health needs of young males with forced migration experiences in Stockholm, Sweden [Manuscript]</p><p dir="ltr">IV. McDonald JT, Dahlin M, Baarnhielm S. Cross-cultural training program on mental health care for refugees - a mixed method evaluation. BMC Med Educ. 2021 Oct 15;21(1):533. PMID: 34654412; PMCID: PMC8520228<br><a href="https://doi.org/10.1186/s12909-021-02965-5">https://doi.org/10.1186/s12909-021-02965-5</a><br></p>