Identifying young people exposed to or at risk of sexual ill health: pilot implementation of an evidence-informed toolkit (SEXIT) at Swedish youth clinics

Experiences of school health professionals in implementing structured assessments of sexual health and experiences of violence among youth in Sweden using the SEXual health Identification Tool (SEXIT): a qualitative sequential study

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.

Understanding the contents and gaps in sexual and reproductive health toolkits designed for adolescence and young adults: a scoping review

INTRODUCTION

Adolescence is a crucial stage of physical and sexual maturation and development and a period in which understanding sexual and reproductive health (SRH) is important. SRH interventions and toolkits provide a range of valuable resources and information to young people, educators, and members of the community on numerous topics, including contraception and puberty.

OBJECTIVES

The usefulness and reliability of these available toolkits have not been previously studied, thus limiting our understanding of their appropriateness and contents. Hence, this scoping review aimed to synthesize the available toolkits aimed at the SRH of adolescents and young adults to understand the contents, design, and information gaps.

METHODS

A systematic search was conducted of 6 medical databases and 12 gray literature sites. Sixteen toolkits published globally before May 2023 were included in our review.

RESULTS

The majority of toolkits (n = 12) contained information related to general SRH knowledge and contraception, whereas only 3 contained information on teenage pregnancy. We found that aiming the toolkits toward educators and health care workers was a favorable design over targeting adolescents and young adults directly and that vulnerable youth-including LGBTQI+ (lesbian, gay, bisexual, transgender, queer or questioning, asexual or allied, intersex, and additional identities) and youth from humanitarian settings-were not well represented.

CONCLUSION

We identified key gaps in the inclusion of information in a range of SRH topics, such as LGBTQI+ sexuality, teenage pregnancy, and safe abortion, in the currently available SRH toolkits and their lack of applicability in a global context. Furthermore, we provide recommendations for areas of improvement to encourage adolescents' agency in their SRH education.

School health-care team members' reflections of their promotion of sexual and reproductive health and rights (SRHR): Important but neglected

OBJECTIVE

Young people are prioritized regarding the promotion and safeguarding of sexual and reproductive health and rights - SRHR. In Sweden, the school is seen as an important arena with members of the school health-care or SHC team as vital actors in this work. This study explored SRHR-related work in SHC teams in Sweden.

METHODS

Within an explorative qualitative design, structured interviews were conducted with 33 nurses, counsellors, SHC unit managers and headmasters. Reflexive thematic analysis was applied, and two main themes found.

RESULTS

SHC team members see SRHR as an urgent topic, but address it only 'when necessary', not systematically - and they experience a shortage of guidance and cooperation regarding SRHR-related work. Even in a country with agreement on the importance of SRHR for all and on providing holistic comprehensive sex education in schools, young people are left to chance - i.e., to the SRHR competence in the professionals they meet.

CONCLUSION

SHC team members in Sweden see SRHR as an urgent topic but do not address it systematically. Moreover, they experience a shortage of guidance for their work. To avoid any professional stress of conscience and for equitable school health care regarding SRHR to be realized, research-informed policy needs to underline systematic, comparable and proactive practice.

Development and usability evaluation of an electronic health report form to assess health in young people: a mixed-methods approach

BACKGROUND

Electronic Patient-Reported Outcomes (ePROs) have potential to improve health outcomes and healthcare. The development of health-technology applications, such as ePROs, should include the potential users and be theoretically grounded. Swedish Youth Health Clinics (YHCs) offer primarily sexual and psychological healthcare for young people aged 12 to 25 years old. Young people in healthcare settings are considered a vulnerable group. The development of a collection of Patient-Reported Outcomes (PROs) in an Electronic Health Report Form (eHRF) for identifying health and health-related problems in young people, was preceded by a qualitative interview study, exploring young people's views on using an eHRF at YHCs and which questions about health an eHRF should contain. The aim of the current study was to develop and evaluate the usability of an eHRF prototype for identifying health and health-related problems in young people visiting YHCs.

METHODS

This study used a participatory design. During the development, an expert panel consisting of eight researchers and one Information Technology worker, participated. A wide literature search was performed to find PROs to construct an eHRF prototype to cover health areas. A mixed methods usability evaluation included 14 participants (young people, healthcare professionals, and an expert panel).

RESULTS

The development resulted in an eHRF prototype, containing ten reliable and valid health questionnaires addressing mental-, physical-, and sexual health and social support, a self-efficacy question, and background questions, in total 74 items. The interviews in the usability evaluation resulted in three categories describing the usability of the eHRF: 'Captures the overall health of young people but needs clarification', 'Fun, easy, and optional and will keep young people's interest', and 'Potential contribution to improve the health consultation'. The quantitative results support the usability of the eHRF for YHCs.

CONCLUSIONS

The participatory approach contributed to development of the eHRF prototype to cover health areas adapted for the target population. The usability evaluation showed that the eHRF was usable and had the potential for self-reflection and contributions to cooperation between young people and healthcare professionals during the health consultation.

Perceived Help and Support for Sex as Self-Injury: A Qualitative Study of a Swedish Sample

Earlier research has found that sexual acts could be used as a means of self-injury, with comparable functions to nonsuicidal self-injury (NSSI) such as cutting or burning the skin. However, no previous study has investigated the experience of help and support in relation to sex as a means of self-injury (SASI), which this study aims to investigate. The study was based on an anonymous open-ended questionnaire published from December 2016 to April 2017 on the websites of NGOs working with help and support for women and youths in Sweden. In total, 197 participants (mostly women, mean age 27.9 years, range 15-64 years) with self-reported experiences of SASI were included in the study. Three main themes were found concerning experiences of help and support for SASI. The need for: (1) Framing the behavior of SASI, to find a word for SASI-to know it exists, to get questions and information about SASI and its function; (2) Flexible, respectful, and professional help and support from an early age, to be listened to and confirmed in one's experience of SASI; and (3) Help with underlying reasons to exit SASI such as finding one's own value and boundaries through conventional therapy, through life itself, or through therapy for underlying issues such as earlier traumatic events, PTSD, dissociation, or anxiety. In conclusion, similar interventions could be helpful for SASI as for NSSI, irrespective of the topographical differences between the behaviors, but the risk of victimization and traumatization must also be addressed in SASI.

Ask me, listen to me, treat me well and I shall tell: a qualitative study of Swedish youths' experiences of systematic assessment of sexual health and risk-taking (SEXIT)

Sexual ill health among young people, in terms of sexually transmitted infections (STIs), unintended pregnancy, transactional sex and sexual violence, is a global public health concern. To that end, the SEXual health Identification Tool (SEXIT) was developed. The purpose of this study was to explore the visitors' experiences of a youth clinic visit when SEXIT was used. A purposively selected sample of 20 participants (16-24 years of age) was recruited from three Swedish youth clinics using SEXIT. Participants were interviewed individually in March and April 2016, and data were analysed using inductive qualitative content analysis. The analysis resulted in four main categories describing the participants' experiences of using SEXIT: "Issues of concern" includes descriptions of the items in SEXIT as important; "Enabling disclosure" describes how SEXIT serves as an invitation to talk and facilitates disclosure of negative experiences; "Road to change" captures experiences of the conversation with the healthcare professional; and "Managing power imbalance" describes experiences regarding the response and attitudes of the healthcare professional as well as the participants' fears of being judged. The categories are connected by the overarching theme "Ask me, listen to me, treat me well and I shall tell". This study contributes knowledge on young people's experiences of a tool-supported dialogue on sexual health and risk-taking initiated by the healthcare professional. Structured questions in a written format, as a basis for dialogue, are appreciated and experienced as a functioning way of addressing sexual ill health and risk-taking at Swedish youth clinics.

Identifying sexual risk-taking and ill health in the meeting with young people-experiences of using an assessment tool

BACKGROUND

Identifying young people exposed to sexual risk-taking or violence is fundamental, when seeking to strengthen their health. However, young people seldom share sexual health concerns or experiences of violence with healthcare professionals (HCPs). Studies evaluating how use of a risk assessment tool influences the dialogue about sexual health and violence are sparse.

AIMS

The aim of this study was to explore HCPs' experiences of using the SEXual health Identification Tool (SEXIT) in encounters with young people at Swedish youth clinics.

METHOD

Three focus group interviews were conducted with 21 HCPs from nine youth clinics, where SEXIT had been introduced. Data were analysed using thematic content analysis.

RESULTS

Three themes were identified. The theme, Facilitates dialogue about sexuality and vulnerability, describes how the questionnaire pertaining to SEXIT helped to normalise and help both HCPs and young people to take part in the dialogue about sensitive issues. Need for a trustful encounter presents HCPs' ethical concerns regarding how the questionnaire affects the integrity of young people and trust-making. Sensitive topics entail challenges describes HCPs' challenges when dealing with sensitive issues. Additionally, it describes needs for knowledge and collaboration when targeting vulnerable young people.

CONCLUSIONS

The HCPs stated that using SEXIT developed their ability to address sensitive issues and helped both them and young people to take part in the dialogue about sexuality and exposure to violence. SEXIT involves experiences of ethical concerns regarding integrity and trust-making. It also entails challenges in having dialogues about sensitive issues, how to deal with risk assessment outcomes and in improvements regarding inter-professional collaborations.

Teenagers' and young adults' sexual behaviour and its associations with exposure to violence, among visitors at a Youth Centre in Sweden

OBJECTIVES

This study aimed to investigate differences between teenagers and young adults in sexual behaviours and exposure to emotional, physical and/or sexual violence, and the associations between sexual behaviours and exposure to violence, among youths who visit a Youth Centre in Sweden.

METHODS

A cross-sectional web survey was used among sexually experienced teenagers, aged 15-19, and young adults 20-24 years, wherein a total of 452 participated. Descriptive and bivariate analyses were used in the study.

RESULTS

A majority had unprotected sex during the last year, namely 55.4 % of teenagers and 58.3 % of young adults. A higher proportion of teenagers reported having early sex debut, before 15 years age, compared with young adults (p = .003). A higher proportion of young adults reported having experienced a sexually transmitted infection (p = <.001). Nearly half of the teenagers (44.9 %) and the young adults (44.6 %) stated having been exposed to emotional, physical and/or sexual violence during their lifetime. Associations were found between all types of exposure to violence and having unprotected sex, using alcohol or drugs together with sex, and having had three or more different sex partners during last year.

CONCLUSIONS

Regardless of age, there was a high proportion of youths, visiting a Youth Centre, having unprotected sex and who experienced exposure to violence. As these experiences may negatively affect youths' future sexual and reproductive health, healthcare professionals should identify youths in need or with early-in-life needs.

Are Screening Tools for Identifying Human Trafficking Victims in Health Care Settings Validated? A Scoping Review

OBJECTIVE

Although many screening tools, resources, and programs for identifying victims of human trafficking exist, consensus is lacking on which tools are most useful, which have been validated, and whether they are effective. The objectives of this study were to determine what tools exist to identify or screen for victims of human trafficking in health care settings and whether these tools have been validated.

METHOD

We conducted a scoping review of the literature on human trafficking identification in health care settings following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) protocol for scoping reviews. We searched the MEDLINE, PsycInfo, Embase, and Scopus databases without language or date limitations. Two independent reviewers screened each citation. We included human research studies in English with populations of all ages, all genders, all geographic locations, and using quantitative and/or qualitative research methods. We excluded studies that were not conducted in a health care setting, review articles, and meta-analyses. We summarized additional screening tools available online and identified through hand-searching.

RESULTS

Database searches yielded 8730 studies, of which 4806 remained after removing duplicates. We excluded 4720 articles based on title/abstract review, we reviewed 85 full-text studies for eligibility, and we included 8 articles. Hand-searching revealed 9 additional screening tools not found in the literature. Through our search for validated screening tools, only 6 had been studied for validation in health care settings.

CONCLUSIONS

Few studies have evaluated screening tools for identifying victims of human trafficking in health care settings. The absence of a gold standard for human trafficking screening and lack of consensus on the definition of human trafficking make screening tool validation difficult. Further research is required for the development of safe, effective approaches to patient screening.

An electronic patient-reported outcome created based on my needs is worth using: an explorative qualitative study investigating young people's opinions for a health assessment tool

BACKGROUND

Young people in different healthcare settings are positive about using electronic patient-reported outcomes (ePROs), which are meant to increase the effectiveness and safety of interventions from the patient's perspective. Sweden offers free healthcare to young people aged 12-25 years at 275 youth health clinics (YHCs), whose goals are to strengthen young people and promote sexual, physical, and mental health. YHCs need effective ways to identify the overall picture of young people's health and health-related problems. To our knowledge, there is no ePRO for YHCs that provides an overview of young people's health from several health perspectives. The aim of this study was to explore young people's view on content and design of an ePRO to provide an overview of their health and health related problems when visiting a YHC, and their opinion on what healthcare needs to consider when using the ePRO. This was an explorative qualitative study. The participants were included from five YHCs, in different socioeconomic areas in central Sweden. Fifteen participants were included: 10 girls, three boys, and two non-binary participants with an age range of 16-22 years. Data were collected using a semi-structured interview guide and individual interviews, and inductive content analysis was performed.

RESULTS

One main theme, "ePRO created based on my needs is worth using" and two sub-themes, "Appealing content and design" and "Trusting healthcare", emerged. The participants wanted that an ePRO should include overall questions about mental-, physical-, and sexual health and social support. Participants also believed the ePRO must disclose the risks of self-harm or suicide. The participants noted the importance of emotional and digital security when using the ePRO and having a confidential conversation with a healthcare provider. To share health information means to trust to gain health.

CONCLUSIONS

The study participants' views on content and design can form the basis for designing an ePRO for young people. Their thoughts on safety and treatment in healthcare can be considered in the development process. This study is the starting point for developing an ePRO for young people at YHCs.

Violence and sexual risk taking reported by young people at Swedish youth clinics

BACKGROUND

Early identification of sexual risk taking and exposure to violence is fundamental when seeking to strengthen young people's health. The purpose of this study was to study factors associated with sexual risk taking and ill health, as well as to study gender differences, and the associations amongst exposure to multiple forms of violence, sexual risk taking and ill health.

METHODS

This was a cross-sectional study based on data from 3,205 young people answering a questionnaire belonging to the Sexual health Identification Tool (SEXIT 2.0), during consultations at 12 youth clinics in Sweden. The analyses are based on descriptive statistics and nominal multiple regression analysis.

RESULTS

Male, transgender and non-binary youths reported significantly more events of sexual risk taking and ill health compared to women. Those who reported sexual initiation before the age of 15 (OR 2.87, CI 1.81-4.56), three or more sexual partners in the past 12 months (OR 2.68, CI 1.70-4.22) and to have ever experienced an unintended pregnancy (OR 2.29, CI 1.32-3.97) were more than twice as likely to report exposure to physical, emotional and sexual violence. Transgender, non-binary youths and women were more exposed to multiple violence (OR 3.68, 13.50) compared to men.

CONCLUSIONS

Transgender and non-binary youths are exposed to significantly more violence compared to women and men. Experiences of sexual risk taking and ill health demonstrated strong associations with exposure to multiple violence.

Staff's experiences of a pilot implementation of the SEXual health Identification Tool for assessing sexual ill health among visitors to Swedish youth clinics: A focus group study

BACKGROUND

Young people are disproportionally burdened by sexual ill health. The SEXual health Identification Tool (SEXIT) was developed for use at youth clinics, to facilitate identification of visitors exposed to or at risk of sexual ill health. The aim of this study was to explore experiences of using SEXIT among youth clinic staff who participated in a pilot implementation, with a focus on usefulness, implementation determinants, and feasibility of implementing SEXIT at Swedish youth clinics.

METHODS

Four focus group discussions were conducted with youth clinic staff from three clinics. The clinics had used SEXIT systematically in consultations with all visitors for one month. Data were analysed using qualitative analysis designed for focus groups.

RESULTS

Most participants experienced that the SEXIT routines were well functioning and that using SEXIT gave a comprehensive picture of the visitor and resulted in more concrete answers, which facilitated the risk assessment. The medical staff experienced that they identified more youth at risk with SEXIT, while the psychosocial staff were less convinced. Existing challenges related to the routines at the clinics and heavy workload during drop-in hours.

CONCLUSIONS

Staff experience SEXIT as useful for identifying young people exposed to or at risk of sexual ill health. Systematic use ensures consistency and quality in assessing the visitors, which may facilitate implementation. The use of SEXIT is challenged by heavy workload, conflicting routines, and the experience that some visitors identified through SEXIT decline further care. Implementation of SEXIT in Swedish youth clinics is considered feasible.