Sweden is one of the countries that has received the largest number of refugee migrants in the EU/EES region [1]. Migrants face structural, socio-political barriers in their resettlement processes such as marginalisation and lack of adequate housing and employment, which affects their health, independent of prior health status [2, 3]. In Sweden, newly settled migrants, with a residence permit based on refugeeship or subsidiary protection status, partake in a national Introduction program [4]. There is a need and a potential to promote health of migrants in the early post-migration stage [5, 6]. One platform, reaching a large part of the newly arrived migrants, is the Civic Orientation (CO), which is a mandatory part of the Introduction program [4].
Health promotion, defined here as actions enabling increased control over and the improvement of one’s health [7], implemented early in the post-migration phase, could mediate ill health caused by systemic inequities and act as a buffer for stressors experienced by migrants [2, 5]. For instance, mental ill health e.g. depression and anxiety are commonly reported, and linked to poor socioeconomic conditions [8], lengthy asylum-seeking processes [9], and experiences of discrimination and isolation [2, 10]. Furthermore, unequal health outcomes between migrant groups and native population are reported beyond the early resettlement process, e.g. mental health, cardiovascular disease and reproductive health outcomes [11,12,13]. Similarly, resources such as social capital, i.e. trusting relationships, social support and networks [14] and health literacy i.e. abilities and resources to find, understand, assess and apply health information [15] are weaker among newly settled migrants than among native born [16, 17]. These resources impact health outcomes and health care utilisation, and the resettlement process as such as they influence participation and empowerment in general [14, 15].
Research on health promotion for newly settled migrants have shown that there is an array of public and non-profit services and programs, e.g. for mental health [18], but that access to these programs is limited by structural barriers [19, 20]. Furthermore, it has been suggested that research on migrants’ health would benefit from continuity and international comparisons [18]. Studies such as this, examining large-scale introduction activities, available across countries and seldom viewed from the migrants’ perspectives on health promotion, are therefore needed.
National Introduction programs focusing on newly settled migrants with a refugee background, also referred to as Establishment Programs or Civic Integration Programs, are common in European and OECD countries [21]. In Sweden, the program includes activities such as Swedish language training, CO, labour market counselling and other activities aimed at facilitating establishment on the labour market and active participation in society [4, 22]. Participation and fulfilment of activities entitles the individual to welfare benefits for a period of 2 years.
The Swedish CO, an integral part of the Introduction program, was streamlined in 2010 by a national law [23]. It is delivered as a course, with a minimum duration of 60 h with learning outcomes related to four knowledge areas, divided into eight learning modules (shown in Fig. 1). The provision of CO is the responsibility of the municipalities that cooperate and coordinate regionally [23, 24]. The course is commonly provided in the largest native languages of participants and delivered by native speaking teachers, referred to as civics communicators. Health information, e.g. the right to health care and how to promote and take care of one’s health in Sweden is included in the course. Based on observed needs, some regions and municipalities offer additional hours of health communication [25]. The added health content includes topics that cover (1) the health care system, (2) self-care, i.e. how to take care of and improve one’s health through life-style changes and (3) other topics of relevance for migrants such as migration and health and mental health, family structure and sexual health. Health communication, defined here as health information delivered in the form of dialogue with participants, is seen by the stakeholders as enabling participants to improve their health, which in turn would allow them to benefit more from introduction activities [24]. The dialogue element was initially discussed and adopted in the bylaw of the CO ordinance [23] to encourage dialogue and reflection as opposed to one-way communication. However, few published studies have examined the potential of the CO with its embedded health communication, e.g. implementation and outcomes, especially from the point of view of the participants [26]. Previous Swedish studies include perceptions of sexual health information [27], health status and self-reported quality of life [28], impact of health information on health outcomes [29], and organisational and collaborative aspects in relation to introduction activities from the stakeholders’ point of view [30, 31]. Research from European and OECD countries on integration policies including CO focus on theoretical conceptualisations and governance aspects [32, 33] and economic, social, and political integration outcomes [34,35,36]; however, the health promotion perspective is generally lacking.
Theoretical framework
Social determinants of health (SDH) refer to the relationship between an individual’s health, and the surrounding social and community networks, living and working conditions, and general socioeconomic, cultural and environmental factors [37]. The study was guided by the concept of SDH throughout, based on the aim of the CO being closely linked to SDH, i.e. to reduce inequalities faced by new migrants by facilitating establishment on the labour market and in society. SDH includes a power dimension and has been defined as ‘life conditions shaped by the distribution of money, power and resources at global, national and local levels’ [38]. Migration involves challenging processes beyond individual behavioural and cultural adaptations to a new context; it encompasses a complex and lengthy process of interactions and negotiations with new social, political, and economical structures [39], a process that intercepts our study. Empowerment is a concept linked to SDH, focusing on processes that moderate social inequalities [40]. Empowerment theory connects individual well-being with the larger social and political environment and has been defined as the process of enabling people to increase their control or power in all ways possible, through resources, education and awareness and by which one can achieve goals and participate in society [40]. We will employ empowerment theory to discuss findings in this study from the bottom-up perspective i.e. that of the participants.
The aim of the study was to explore participants’ perceptions and experiences of Swedish civic orientation with added health communication.
