Mid Sweden University

Objective: This study explored how 15–16-year-old adolescents experience communication about SRHR within the school setting, among peers and family, and in digital contexts, as well as their perceived needs and gaps in support.

Methods: Eight focus group discussions (FGDs) were conducted in March 2024 with 40 adolescents (aged 15–16 years) in Sweden, separated by sex (F = 19; M = 21). The FGDs were recorded, transcribed and analysed using qualitative content analysis.

Results: Three categories summarised the findings: the pervasive nature of online sexual and psychological violence, illustrating the context in which adolescents live and interact daily, where exposure to unsolicited sexual content reinforce normative sexual scripts; gendered imbalances in SRHR communication, highlighting how male adolescents often carried their SRHR-related concerns in silence, while their female peers generally had more socially accepted avenues for discussion; and unmet needs for SRHR communication within the school setting, emphasising the mismatch between provided content and adolescents' expressed needs. The categories were connected by an overarching theme – bridging gaps in adolescent SRHR awareness through open communication – emphasising the adolescents' desire for adult-initiated conversations and regular exposure to SRHR topics.

Conclusions: The adolescents described feeling ill-equipped to navigate SRHR-related concerns and experiences of online sexual violence, and they had unmet needs for conversations about SRHR with teachers and school health professionals. Routine and open discussions within the school setting, initiated by adults, could be key to addressing existing gender imbalances and stereotypes by normalising SRHR conversations and encouraging help-seeking behaviour. 

Introduction Despite free student health services in Sweden, subjective health complaints (SHC) and violence remain common among adolescents. Evidence on how different forms of violence relate to these symptoms is limited. This study examined associations between multifaceted violence and SHC among adolescents by sex and sexual orientation.

Methods A cross-sectional digital survey (2024) was conducted among first-year upper-secondary students in a sparsely populated county of Sweden, covering approximately one-tenth of the national land area (n=668; 76%). SHCs measured using the Health Behaviour in School-aged Children symptom checklist. past-year victimisation (physical, psychological and sexual), childhood witnessing of violence and perpetration were assessed using items adapted from the Sexual health Identification Tool. Demographic variables included sex, place of birth and sexual orientation. Descriptive statistics and sex-stratified hierarchical regression analyses were conducted.

Results Overall, 15.3% reported past-year violence exposure, more commonly among girls than boys (17.1% vs 12.4%, p<0.001). Boys more often reported repeated physical victimisation and physical perpetration, whereas girls more frequently reported psychological victimisation and witnessing psychological violence during childhood. Non-heterosexual adolescents reported higher violence exposure scores and higher levels of several SHC compared with heterosexual peers. In sex-stratified regression analyses, experienced violence was independently associated with higher SHC scores among both girls (β=0.245, p<0.001) and boys (β=0.175, p=0.004). Witnessed violence during childhood was also independently associated with higher SHC among girls (β=0.245, p<0.001) and boys (β=0.133, p=0.029). Sexual orientation remained independently associated with higher SHC only among boys (β=0.220, p<0.001).

Conclusions Violence exposure patterns differed by sex, while sexual-minority adolescents reported greater violence exposure and symptom burden. Both experienced and witnessed childhood violence were independently associated with higher SHC, indicating that violence-related health consequences extend beyond direct victimisation. Further research and prevention efforts should better recognise diverse violence experiences, including boys who are often primarily framed as perpetrators rather than victims and sexual-minority youth.

Background

Dental caries remains one of the most prevalent chronic conditions in preschool children and disproportionately affects families in socioeconomically vulnerable contexts, despite publicly funded preventive dental care. In Region Västra Götaland, Sweden, a theory-based behavioural intervention delivered by health promoters was introduced to support families of children at elevated caries risk. The aim of this study was to describe the different ways in which parents conceive a health-promoter-led, theory-based behavioural intervention to prevent dental caries in their preschool-aged children.

Methods

A qualitative study using individual, semi-structured interviews were conducted in ten public dental clinics in Region Västra Götaland, Sweden (March 2023–July 2024). Interviews were analysed using phenomenographic analysis to capture variation in parental conceptions. Ten parents (eight women, two men) of three-to-six-year-old children at elevated caries risk completed two or more counselling sessions with university-trained health promoters. Interviews (30–60 min) were audio-recorded, transcribed verbatim and analysed inductively to capture variation in parental perceptions. Flexible delivery (digital/in-clinic) and interpreter support were made available.

Results

Three themes were identified: (1) an invitation met by ambivalence and fear of judgement, (2) empowered alliance through personalised support and (3) active choices through parental agency. These themes coalesced into the overarching theme ‘from ambivalence to agency: embracing health-promoting behaviour’.

Conclusions

Parents conceived the health-promoter-led, theory-based behavioural intervention as non-judgemental, culturally responsive and practically useful. By fostering relational safety and providing actionable tools, the intervention appeared to strengthen parental self-efficacy and catalyse family-level behavioural change. This shift, while modest in scale, may represent a necessary step towards equitable and sustainable oral-health promotion.

Comprehensive Sexuality Education (CSE) is central to promoting adolescents' sexual health and rights. In Sweden, CSE is now referred to as Sexuality, Consent and Relationships (SCR) education, following a curriculum revision in 2022. This study explored how upper secondary school students (aged 16-19) experienced SCR education. A digital questionnaire was completed in the classroom by 1378 students (68% response rate) in early 2025, and data were analysed using bi- and multivariate methods. Most participants (61%) reported receiving sufficient education, yet notable gaps and inequalities were evident. Girls and non-heterosexual students were more likely to describe their education as insufficient. One in four students wished SCR contents had been covered more extensively, particularly violence in relationships - a theme viewed as important but often overlooked in teaching. These findings highlight disparities and unmet needs in SCR education, suggesting inequitable access to comprehensive and inclusive teaching relevant to students which may constrain their ability to build informed, respectful, and safe relationships. Strengthening the implementation of Sweden's SCR curriculum is therefore essential to ensure equitable learning opportunities that reflect young people's diverse realities.

Background

Placement breakdowns in foster care are a recurrent phenomenon with serious negative consequences for children’s health and well-being. Despite policy initiatives to strengthen stability, the problem persists.

Aim

To explore foster parents’ perceptions of placement breakdowns in foster care.

Method

Semi-structured interviews (60–100 min) were conducted in spring 2025 with ten foster parents from different Swedish municipalities, all with direct experience of breakdowns. Data were analysed inductively using qualitative content analysis.

Results

The analysis generated an overarching theme: the need to address systemic shortcomings to prevent breakdowns and mitigate their emotional consequences. Five categories supported this theme. First, foster parents reported a lack of recognition of their role, including limited legal rights, insufficient trust in their competence, and unequal or insecure remuneration. Second, they described inadequate support, both in quality and accessibility, often linked to limited resources within social services, while consultant agencies were considered more responsive. Third, the absence of a child perspective in relocation decisions was emphasised; children’s voices and life circumstances were rarely considered, preparation for moves was insufficient, and post-placement contact was usually severed. Fourth, respondents highlighted a lack of legal safeguards, with poor follow-up, unclear grounds for relocation, and a power imbalance between foster parents and social services. Finally, breakdowns were experienced as emotionally damaging, leading to foster parents’ emotional withdrawal and children’s attachment difficulties.

Conclusion

The findings reveal systemic deficiencies that heighten the risk of breakdowns and threaten stability in foster care. Structural reforms are needed to strengthen recognition, provide adequate support, safeguard rights, and embed the child’s perspective.

Background Physical activity on prescription (PAP) is a recommended method in Swedish and European primary healthcare, yet implementation remains inconsistent. This study explored barriers and strategies for strengthening PAP use in a region with low prescription rates, from the perspective of healthcare personnel and managers. Methods A mixed-methods study with an explanatory sequential design was conducted (2024) in a geographically dispersed Swedish region. Digital surveys with healthcare personnel and managers (n = 93) were analysed using uni-, bi- and multivariate analyses, followed by semistructured interviews (n = 14) analysed with qualitative content analysis guided by Normalization Process Theory (NPT). Results The survey was completed by 75 healthcare personnel and 18 managers. Most healthcare personnel (84%, n = 58/69) reported providing basic PA advice regularly, but only 16% (n = 12/74) prescribed PAPs. Physiotherapists prescribed PAP more often than other personnel (32%, n = 8/25 vs. 8%, n = 4/47; p = .018), and this remained significant in adjusted analyses (OR 4.0, 95% CI 1.01-15.83). Documentation of PAP components according to the Classification of Health Care Interventions (KV & Aring;) was generally low. Physiotherapists more often reported high or very high competence in counselling compared with other healthcare personnel (100%, n = 27/27 vs. 72%, n = 34/47; p = .003), prescribing PAP (74%, n = 20/27 vs. 36%, n = 17/47; p = .003), and follow-up (78%, n = 21/27 vs. 32%, n = 15/47; p < .001). Female healthcare personnel expressed stronger trust in PAP evidence than males (p = .013). Few personnel had received PAP training (38%, n = 28/74), and most were unaware of existing guidelines (81%, n = 61/75). Time constraints (53%, n = 41/75) and lack of guidelines (48%, n = 38/75) were the most common barriers, with older healthcare personnel (>= 46 years) more likely to report time constraints (OR 3.6, CI 1.27-10.16). Managers more often highlighted unclear purpose of PAPs and patient reluctance, whereas personnel emphasised lack of training and managerial prioritisation. Despite these differing perspectives, 69% (n = 50/72) of healthcare personnel and 75% (n = 12/16) of managers endorsed increasing PA counselling. Conclusions Strong interest in PAPs indicates favourable conditions for sustainable implementation if legitimacy-building education (coherence), tailored resources and training (cognitive participation), multilevel leadership commitment (collective action), and coordination for monitoring (reflexive monitoring) are secured. These are necessary strategic investments, transferable beyond Sweden to systems facing PAP implementation challenges.

During the COVID-19 pandemic, Sweden adopted a recommendation-based approach rather than strict lockdowns. This approach relies on public willingness to adhere to guidelines and motivations for prosocial behaviour. This study aimed to explore the motivations behind adherence or non-adherence to COVID-19 recommendations in Sweden. Semi-structured interviews were conducted in 2022 with 20 participants aged 26 to 63, all residing and working in Stockholm. The interviews were conducted via online platforms, Teams and Zoom, transcribed and analysed using content analysis. The analysis yielded two overarching themes that motivated adherence or non-adherence, Sacrificing comfort for collective wellbeing and A sense of being superior and able to handle national recommendations in your own way derived from six categories: (i) Social pressure and the desire to appear prosocial, (ii) Embracing a new reality as a means to return to normalcy, (iii) The absence of punitive measures for non-adherence, (iv) Creating safe environments and circumventing the system, (v) Negotiating which recommendations to follow and (vi) Diminished adherence over time. Adherence to public health recommendations was driven by social pressure and a desire to protect loved ones, often requiring personal sacrifices and behavioural adjustments. Conversely, non-adherence stemmed from a sense of autonomy, mental well-being preservation and tiredness, highlighting the challenges of sustaining compliance over time. 

Background: The Swedish model for contraceptive counselling is well developed, with free and easily accessible services, and contraceptives that are free or subsidised. Despite this, many women have an unmet need for contraception. Aim: The aim of this study was to investigate the reasons for not using contraceptive methods at the time of conception among abortion-seeking women, and to identify factors associated with unawareness of their potential to become pregnant at that time. Methods: A multi-centre cross-sectional survey was conducted among 623 abortion-seeking women at seven family planning clinics in Sweden in 2021. The questionnaire comprised 39 items, one of which explicitly addressed the reasons for not using contraception at the time of conception. Bivariate and multivariate analyses were conducted using odds ratios (ORs) and confidence intervals (CIs). Results: Of the 623 women, 387 reported not using contraception at the time of conception. The most common reason was unawareness of their potential to become pregnant at that time, considered as low fertility awareness (LFA), reported by 142 (37%) women. No significant sociodemographic or lifestyle differences were found between women with LFA and those reporting other reasons for not using contraception. However, LFA was more common among women who had not used contraception in the previous 12 months (OR = 2.912, CI: 1.844–4.601), and previous abortion experience was a protective factor (OR = 0.617, CI: 0.398–0.958). A significantly lower proportion of women reported contraceptive use at the time of conception compared to the preceding year. Conclusions: LFA is common and linked to no contraceptive use in the previous year and no prior abortion history, and contraceptive use at conception is lower than over the preceding year indicating gaps in continuity and adherence. These findings support service models that turn counselling into timely initiation with verified uptake and sustained use. 

Introduction: Dental caries remains a prevalent condition with significant health and economic repercussions. To address persistent oral health disparities and reduce the burden of dental caries among preschoolers in Sweden, this study aims to evaluate the clinical and economic impact of implementing a theory-based behavioural intervention delivered by health promoters in clinics serving children at elevated risk for caries.

Methods: A retrospective cohort design was applied, comparing clinics using a theory-based behavioural intervention led by health promoters with clinics using the Recommended Programme for Caries Treatment (RPCT). The cohort were children aged 3-6 years identified as being at increased caries risk in Region Västra Götaland during 2021-2023. Three analytic approaches were employed: (1) budget impact analysis (BIA) to measure net costs and resource shifts; (2) difference-in-differences (DiD) to compare mean decayed, extracted or filled teeth (deft) in intervention versus control clinics; and (3) cost-effectiveness analysis (CEA) to estimate the incremental cost-effectiveness ratio (ICER).

Results: The BIA showed that the theory-based behavioural intervention led by health promoters incurred higher initial personnel costs than the RPCT but required fewer clinical hours - an opportunity cost that, if redeployed to clinical activity, could partially offset these expenses. The DiD showed that, over 3 years, clinics implementing the intervention achieved a statistically significant reduction of 0.26 deft among 6-year-olds. The CEA estimated the ICER to be 2142 SEK (199 EUR) per deft prevented, which improved to 513-810 SEK (48-75 EUR) when the economic value of the liberated work hours was included.

Conclusion: A theory-based behavioural intervention led by health promoters reduced caries risk among high-risk preschoolers and may enable improved resource allocation, contingent on the redeployment of freed hours. Despite higher initial personnel costs, the approach demonstrated favourable cost-effectiveness over time, supporting its integration into public dental care systems.

Introduction Poor sexual and reproductive health (SRH) is a global public health concern, particularly among adolescents. While school health services (SHS) play a crucial role in preventative care, professionals are inconsistent in addressing SRH issues. This study explored school health professionals’ (SHPs) experiences of an implementation of structured assessments of sexual health and experiences of violence among youth in Sweden using the SEXual health Identification Tool (SEXIT).Methods A qualitative sequential study was conducted from October 2023 to January 2024 to explore the experiences of 57 SHPs trained in the SEXIT method. Data collection included a questionnaire with open-ended questions, group discussions and individual interviews, analysed using qualitative content analysis.Results Addressing sexual risk taking and violence was considered a priority to help youths make informed SRH choices. SEXIT aided SHPs in acting as educators to promote SRH and freedom from violence, normalised conversations about sensitive topics, facilitated the identification of students needing support, and could be integrated as a routine part of preventive work within SHS. However, hindering factors for effective implementation included a lack of supportive leadership and a unified approach among involved organisations to clarify roles, responsibilities and referral pathways. Furthermore, it is essential to further adapt SEXIT and train SHPs to meet the specific needs of vulnerable youths and perpetrators, ensuring equitable support.Conclusions SEXIT offers unique opportunities for SHPs to discuss SRH and violence with school youths, a priority part of their preventive work; however, it is not routinely used, underscoring the need for supportive leadership and a unified approach among organisations.