Exploring young people’s experiences of equity in relation to everyday challenges: a focus group study

doi:10.21203/rs.3.rs-1997486/v1

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Research Article

Exploring young people’s experiences of equity in relation to everyday challenges: a focus group study

https://doi.org/10.21203/rs.3.rs-1997486/v1

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published 22 Mar, 2023

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Background

Reports indicate a decrease in youth mental health in Sweden but at the same time research suggests that what is interpreted as mental ill-health could be considered everyday challenges by young people themselves. The distribution of mental health and illness among young people is also uneven, due to structural inequities related to factors such as race, gender, and socioeconomics. Sweden in particular is a country with large socioeconomic inequities in youth mental health and in school results, compared to other European countries. The aim of the study was to explore young people’s experiences of equity in relation to everyday challenges, with a focus on race, gender, and socioeconomics.

Methods

Sixty-five young people aged 13–15 years old were recruited by student health services and participated in focus group discussions at schools in the southernmost part of Sweden. Data was analyzed by secondary analysis with deductive qualitative content analysis, using the ecosocial theory of disease distribution as theoretical framework.

Results

The analysis resulted in one main theme: Navigating equity factors to gain and keep status, with three underlying themes: Guided by social norms, Negative impact in everyday life, and Importance of family influence. Participants were aware and critical of norms and expectations related to race, gender, and socioeconomics. Experiences of prejudice and unfairness were both the participants’ own lived experiences and based on observations of friends and school mates.

Conclusions

Young people identify equity issues related to race, gender, and socioeconomics in their everyday life. Passing norms and expectations related to these issues is a way to lose and gain status in a school setting. Many of the inequities discussed are related to socioeconomics and the direct consequences of having or not having money. Young people’s everyday experiences of equity issues are important to consider in youth mental health promotion aiming to tackle health inequities. Further research is needed on those experiences and how they affect mental health.

Everyday challenges

health equity

qualitative study

youth mental health

Globally, mental problems are among the leading causes of illness among young people (1). In Sweden a majority of young people report good mental health and well-being, but it is not equally distributed(2) between different groups. A similar pattern of inequities as observed in health in general can also be seen in youth mental health. Girls, young people of gender and/or sexual minorities, young people from families with lower socioeconomic status, and young people with a migrant background, report lower levels of mental health and well-being compared to other groups (3).

Previous research shows differences in youth mental health depending on migration status, and young people of immigrant background report a higher prevalence of mental health problems compared to young people of Swedish background, also after controlling for socioeconomic status and gender (4). Another study by Mittendorfer-Rutz et al. (2) suggests that unaccompanied minors in Sweden have a suicide rate that is eight times higher than young people in the host population. Factors explaining the higher rates of mental health problems among people with a migrant background, include migration trauma, changes in family structures, and intragenerational conflicts due to the migration process (5), as well as discrimination and socioeconomic factors (6).

Boys generally report higher levels of mental health compared to girls. In Sweden a majority of 15-year-olds report good mental well-being, but there is a gender gap with 66 percent of girls compared to 85 percent of boys reporting good mental well-being (3). Girls also report higher rates of psychosomatic symptoms compared to boys, globally as well as in Sweden (1). Furthermore, boys rate their self-efficacy higher than girls, with 87 percent of the boys and 81 percent of the girls reporting that they always or often can find solutions to their problems (3), which could contribute to boys’ better mental health status. However, contradictory though it may seem, even though boys report better mental health than girls, they at the same time account for 55 percent of child suicides in Sweden (7). Hellström and Beckman (8) noted gendered differences in the coping strategies to deal with bullying, with adolescents perceiving girls to be better at talking to friends about being bullied and boys being more tolerant towards mean comments, as a confrontation might result in physical violence.

The pattern of socioeconomic inequities in self-rated health is similar among girls and boys. Among girls from low-affluence families, 30 percent report good health compared to 50 percent among girls from high-affluence families. A similar difference is seen among boys, where 40 percent of boys from low-affluence families and 58 percent of boys from high-affluence families report good health (1). Global research also shows that young people from socioeconomically disadvantaged families have a two- to three-fold higher risk of developing mental health problems, compared to those with families of a higher socioeconomic position, also in high-income countries (9, 10). According to the World Health Organization (1), Sweden is among the countries with the largest socioeconomic inequities in youth self-rated health in Europe, only England and Azerbaijan having a bigger gap between young people of low and high socioeconomic status. The report “Equity in school education in Europe” (11) shows a similar pattern related to school results, with Sweden having a larger socioeconomic gap in school results compared to the European average.

Many studies of youth mental health are based on data from the “Health Behavior among School-Aged Children” survey that is conducted every fourth year in several countries in Europe and North America, including Sweden. This survey shows a decline in mental health, related to higher rates of reported psychosomatic symptoms (1). A majority of Swedish youth still report good mental health through the survey but there has been an increase in psychosomatic symptoms, such as headaches, stomach aches, sleep difficulties, and bad mood, in recent years (3). However, a study by Wickström and Lindholm (12) indicates that young people do not necessarily understand the psychosomatic symptoms reported in the survey as deeper mental health problems, but as a part of everyday challenges. Another study also indicates that young people may understand the survey as normative and dictating what is right and wrong regarding health, family situation, and material standard (13).

The terms “equity” and “equality” are often used interchangeably but differ slightly in meaning. In the report “Closing the gap in a generation,” Marmot et al. (14) define health inequalities as differences in health, while health inequities are the unjust and avoidable inequalities in health. Closing the health inequity gap in a generation is also a goal of the Swedish government. The appointed Commission for Equity in Health emphasizes the importance of schools in reducing health inequities among children, both in the present time and with regard to their future as adults (15). Therefore, this study addresses youth perception on equity in everyday school life.

There are many theories aiming to explain health inequities and the uneven distribution of health and illness. The purpose of the ecosocial theory of disease distribution is to describe how disease and health are distributed in the population by combining a biological and a psychosocial perspective (16). Experiences of discrimination and injustice are embodied and thus affect the health of the individual. The theory also considers the time aspect by including a life course and an inter-generational perspective. Ecosocial theory differs from theories that aim to explain health inequities using biomedical models or theories regarding differences in lifestyle factors. Ecosocial theory pays attention to the social system that creates discrimination and inequities and sees this as contributing to an uneven distribution of disease and health (17). At the center of the theory lie inequities related to socioeconomic status/class, gender/sexuality, and race/ethnicity (17).

Youth mental health is a concern globally as well as in Sweden. Despite the vast knowledge of youth mental health and inequities there seems to be a lack of studies exploring young people’s own perception and experiences of inequities in everyday life and in relation to everyday challenges. In light of previous studies (12, 13) indicating that young people might have a different interpretation of psychosomatic symptoms reported in surveys, compared to the interpretation made by researchers and the public, it is important to include young people in research regarding youth mental health and to further explore youth perceptions of the manifestation and effect of everyday challenges. Knowledge of young people’s understanding of inequities is crucial in mental health equity promotion. The aim of the present study was to explore young people’s experiences of equity in relation to everyday challenges, with a focus on race, gender, and socioeconomics.

Design

The study is part of a larger project aiming to develop a school-based mental-health-promoting intervention, with a focus on supporting young people in handling everyday challenges. The project has a participatory design to involve young people as co-researchers. This study is conducted using qualitative secondary analysis of focus group discussions aiming to explore everyday challenges among young people. Doing a secondary analysis on qualitative data involves re-using already existing data from previous studies. This can be a useful method to make use of collected data that did not fit the original aim (18). Participants in the primary study were not asked specifically about equity, socioeconomics, race, or gender, and the parts included in the unit of analysis consist of segments where the participants spontaneously discussed these issues.

Data collection

Students from schools in the county of Scania in southern Sweden participated in focus group discussions. Focus groups are a commonly used method of data collection in youth research as it is a good method to engage participants through group interaction and to explore the issue at study collectively (19). Each focus group met on three occasions, with every occasion having a different topic. This study is based on the data from the first occasion, which consisted of the participants identifying and discussing what their everyday challenges could be. Each focus group was asked to divide themselves into smaller groups to discuss and write down everyday challenges. They were then asked to present their discussions to the whole group. The discussions were recorded, and photographs were taken of the participants’ notes. Only the transcribed recordings were used as the data for this study.

Study population

The participants were recruited with the help of the school nurse at each school. Students with an interest in discussing everyday challenges were asked to participate. Exclusion criteria were not speaking Swedish and/or having severe mental ill-health. Written informed consent was collected from the participants, and for those under the age of 15 written informed consent from legal guardians was also collected.

In total, 65 young people participated in seven focus groups with between 4 and 11 participants in each group; 45 were girls and 20 were boys (see Table 1). The participants were not asked about their gender; instead, the gender of the participants was assumed by the focus group moderators based on participants’ appearances. The study participants were young people aged 13-15 years old. The schools were located in areas with varying socioeconomic conditions, but with an emphasis on schools in areas with good socioeconomic conditions. The focus groups were conducted at the participants’ schools during school hours, with a mix of students from grade 7 to grade 9, which meant that participants had some knowledge of each other.

Table 1. Participants in focus groups.

Focus group number	Girls	Boys	Total
School 1	3	7	10
School 2	8	2	10
School 3	2	6	8
School 4	8	2	10
School 5	11	0	11
School 6	3	1	4
School 7	10	2	12

Data analysis

The focus group discussions were transcribed verbatim. Qualitative content analysis was used to analyze the data. This method was chosen as it is an appropriate method to explore experiences and as it also allows for searching for a variation in the data (20, 21). First, a deductive approach was applied to select the unit of analysis, using the ecosocial theory of disease distribution. The transcripts were read through and data concerning gender, socioeconomics, and race was identified and selected as the unit of analysis. There was a variation between the different focus groups regarding how much they discussed race, gender, and socioeconomics; hence, some focus groups provided a lot of data, while some provided less data. The selected unit of analysis was then analyzed using an inductive approach to explore young people’s experiences of race, gender, and socioeconomics in relation to everyday challenges. The unit of analysis was read through several times in order to understand the concept in focus and find variations within the text. Notes were taken of preliminary thoughts and ideas for analysis.

Once the unit of analysis had been selected, the next step of the analysis was to identify meaning units and condense the data. The purpose of condensing the data was to shorten and find the core of words, sentences, and paragraphs that shared the same content (20). This made the data more manageable when moving further on in the analysis. Some of the data material was considered already condensed, while other parts were condensed by the first author. The division of the data into meaning units, and condensation when needed, was followed by labeling the meaning units with codes. The codes were kept close to the data, aiming to capture how the participants discussed the issues. When the entire material was coded, the codes were read through and sorted into sub-themes based on similarities and differences between the codes. The sub-themes were sorted into themes and finally into one main theme; see Table 2. The sorting of codes and the creation of themes were a back-and-forth process with sub-themes and themes being created and re-created until the analysis was considered to capture the essence of participants’ discussion. The codes, sub-themes, and themes were also discussed with the co-authors who participated in the data collection. The full transcripts and the unit of analysis were read through several times in the last stages of the process to ensure that the analysis captured the voices of the participants. The first author also went back to notes being taken regarding initial thoughts and observations of the data.

Table 2. Examples of steps in the analysis.

Meaning unit	Condensed meaning unit	Code	Sub-theme	Theme
No, you shouldn’t [have to accept racism], but it still happens	-	Should not have to stand racism	Questioning unfair norms	Guided by social norms
Let’s say that I’m Christian and I want to change [gender], then it’s not, maybe my parents think it’s not acceptable since it’s not a part of the religion.	If I’m Christian and want to change gender my parents might not accept it	Maybe not accepted to be trans when Christian	Dealing with parents’ opinions	Importance of family influence
And if you don’t [wear designer clothes] it’s easy to be left outside	-	Left outside if not wearing the right clothes	Being left outside	Negative impact in everyday life

The analysis resulted in one main theme: Navigating equity factors to gain and keep status, with three underlying themes. The themes and sub-themes are presented in Table 3.

Table 3. Main theme, themes, and sub-themes.

Main theme	Navigating equity factors to gain and keep status
Themes	Guided by social norms	Negative impact in everyday life	Importance of family influence
Sub-themes	Money equaling status	Experiencing prejudice	Family affluence affecting
	Musts being gendered	Causing insecurity	Dealing with parents’ opinions
	Being of different background	Being left outside	Feeling pressure for a good future
	Questioning unfair norms

Guided by social norms

This theme was constituted by four sub-themes: Money equaling status, Musts being gendered, Being of different background, and Questioning unfair norms. The participants were aware of and reflected on how factors such as race, gender, and socioeconomics impacted their lives. They expressed awareness of which norms they had to navigate in order to gain and keep status. The impact of race, gender, and socioeconomics was often expressed in terms of stress or pressure. Norms and expectations guided the participants’ behavior and reasoning in everyday life, but at the same time they were critical of them, expressing that you should not have to follow these norms and expectations.

Fitting in with the social norms, for instance, having money, could give you status. This was expressed by one participant in the sub-theme Money equaling status:

Girl 1: “Here [where we live], there is a lot of baiting about money, you should always be the best and be better than everyone, that is something that we thought about.”
Interviewer: “Could you elaborate on this baiting? How can you experience that at your age?”
Girl 2: “There’s a lot of competitions, like who has the most expensive clothes and stuff like that.”
(School 5)

Having money was described to be an important status marker that could be stressful to uphold. Not being able to afford certain things, could mark you out as being of low status, as expressed by another participant who discussed the many ideals you are supposed to live up to:

“How you should be and look, what stuff you’re supposed to have, which is linked to money. If you don’t have the newest cellphone, you’re considered poor, or if you don’t have designer clothes, don’t have a lot of money, don’t live in a fancy neighborhood and stuff like that.”
(Boy, School 4).

Some of the everyday expectations were thought to be gendered, as expressed within the sub-theme Musts being gendered, where participants discussed how norms were different for boys and girls. The expectations to be met in everyday life were seen as conforming to traditional gender roles, girls being more concerned with their looks than boys. However, the importance of designer clothes was considered more of a burden for boys, while at the same time boys were described as being more free to wear whatever, and look however, they wanted, as expressed by some participants.

Girl 1: “Guys can wear sweats, but us girls, make-up, hair, jeans, well everything. We have to, ‘I have to have a body’. Guys don’t think about the body, it’s more girls.”
Boy 1: “I can agree with that.”
Boys 2: “I can put on anything, then I go to school.”
(School 1)

Another equity-related aspect affecting everyday challenges was described as background. Social factors such as race, culture, religion, language, and nationality were all discussed under the label of background. Background was often highlighted in terms of “different background,” expressing that it deviated from the norm, within the sub-theme of Being of different background. The norms related to “background” became visible by what was labeled as “different.” Examples of what was deemed different were: not being white, not being Swedish, or not being a secular Christian. Being one of those seen as “different” meant not being able to go unnoticed, as described by one participant:

“It was like, people didn’t think it was weird but still said ‘that’s so weird, isn’t it super weird to not celebrate Christmas like everyone else, what do you do on Christmas Eve?’. And she didn’t like hearing this, it became a big deal in school.”
(Girl, School 6)

Within the sub-theme Questioning unfair norms, the participants reflected on social norms and how they provide different opportunities. This was often discussed in a spirit of solidarity with others, such as awareness of the fact that the pressure to wear expensive clothes or to engage in expensive activities would hit some peers, who could not afford these things, harder. Some also expressed that you should not have to suffer negative consequences because of your socioeconomic position or your race but saw that it still happened. Participants could relate to this unfairness through observing friends as well as through their own experiences of feeling that others were better off.

In addition to identifying specific social norms and being aware of related injustice, the participants were also critical of these social norms and of the prejudice they implied. Despite expressing some norm compliance, they were critical of the normative expectations related to, for instance, gender and race, and the impact they had in their everyday life. Participants also expressed criticism of how adults foisted normative expectations on them.

“We have cafeteria hosts at school, who are supposed to clean up after others and stuff like that. And then she, the same teacher, says ‘I understand if the guys don’t want to clean, but you girls have to clean since you’re going to be mothers’ and such things. … And that causes us to be late for class.”
(Girl, School 1)

Although aware and critical of being guided by social norms, participants attempted to navigate these norms and expectations to the best of their ability, as they were also aware of the consequences of not fitting in with the norms.

Negative impact in everyday life

This theme consists of three sub-themes: Experiencing prejudice, Being left outside, and Causing insecurity. Participants were highly aware of the negative impact of the structural norms related to race, gender, and socioeconomics in everyday life when not being able to navigate them. The negative impact experienced could be direct and outspoken as well as more indirect and subtle.

In the sub-theme Experiencing prejudice, participants shared experiences of, for instance, racism, classism, sexism, and homophobia in everyday situations. These experiences included words related to race or sexual identity being used as bad words in general, but also slurs on individuals.

“And it’s the same with race and stuff, that you often hear. Well, not often since we’ve outgrown it by now. Let’s say that if you have dark skin, you are worth less because those with dark skin are a minority. More people are white.”
(Boy, School 6)

Aside from prejudice, most of the negative impacts of social equity factors in everyday life that the participants experienced and discussed were subtle and indirect. This was illustrated by the sub-theme Being left outside, where participants expressed feelings of becoming an outsider if not complying with norms and expectations. One aspect discussed was not having enough money, which could mean not being able to join friends at different activities. Some participants discussed how not being able to join expensive activities could lead to exclusion from the friend group, and to being forgotten and no longer invited by the friends. Not being left outside was discussed as important and something you are willing to make sacrifices to avoid, which one participant expressed like this:

“Like school lunch, maybe there’s a dish that you would have eaten but nobody else wants to eat it. So, they go to McDonald’s or Burger King and you don’t want to sit by yourself in the cafeteria, so you join [them], but you don’t have any money for it. So, you just sit there and skip lunch to be with your friends. And that affects you at school and stuff.”
(Boy, School 3)

Another negative effect, in everyday life, of structures relating to socioeconomics, race, and gender is described in the sub-theme Causing insecurity. Constant comparison with peers contributed to feelings of insecurity and trying to fit in with the norms was also seen as a result of insecurity. Breaking norms, or the risk of others perceiving that you are not fitting in with the expectations related to race, gender, and socioeconomics, is described as scary.

“Or sexuality, many use ‘gay’ as a slur and people might, people feel bad because of that and don’t dare come out. You don’t want to stand out from the crowd, because there will always be someone judging you and commenting on it.”
(Boy, School 4)

The participants shared experiences of negative impacts related to inequities and stated that avoiding these negative impacts by navigating them was not always possible. Many of the experiences revolved around school and friends, but there were also experiences of negative impacts due to adults, such as school staff or family members.

Importance of family influence

This theme comprises three sub-themes: Family affluence affecting, Dealing with parents’ opinions, and Feeling pressure for a good future. Influence of family was yet another aspect that had to be considered by the participants as they navigated social norms. Family and parents had a big influence on the participants’ experiences related to race, gender, and socioeconomics, both in the sense that parental background was experienced as inherited and because the opinions and values of parents affected the participants.

The sub-theme Family affluence affecting concerns having families both with high affluence and low affluence. The level of family affluence was perceived relative to the affluence of friends or school mates, rather than to a larger societal context. Comparing your own family with the family of friends was described as causing stress.

Girl 1: “Self-baiting… We thought about..., what did we think about?”
Girl 2: “Yeah, for example, ‘my friend has a really big house that I don’t have’ or ‘my friend’s mom has a really nice new car, my mom doesn’t have that’.”
(School 6)

Family socioeconomic background was considered directly related to the socioeconomic status of the individual. Participants discussed how coming from a poor background could lead to mental illness and problems in the future. Certain factors, such as having divorced parents, were perceived as increasing the risk of financial problems and related effects.

In the sub-theme Dealing with parents’ opinions, participants discussed how they dealt with parents having different opinions or values than themselves. These differences were described as depending both on background and on prejudice about other groups or people. The “background” of parents was discussed as influencing how strict parents were in their approach to their children. “Background” was understood to relate to the national, ethnical, and religious background of parents, often talked about and labeled as “different background” when discussing parents not born in Sweden and/or religious parents. Parents could also voice prejudice, which was discussed as influencing younger siblings and difficult to deal with. One participant reflected on how these opinions affected their family reputation in a negative way:

“My dad can also, not like that, but my dad can also be a bit condescending to people from other countries, like Muslims, and my little brother passes this on. And that makes us look worse…”
(Girl, School 6)

The sub-theme Feeling pressure for a good future consists of feelings and perceptions of stress from family, to reach what is seen as a “good” future. Different future occupations are labeled with different status, as expressed by some participants:

Boy 1: “You have to think about your future.”
Boy 2:” I don’t think anyone here wants to work at Lidl [a discount supermarket].”
Boy 3: “Working at Lidl is better than cleaning.”
Boy 2: “Those who clean make more money than those working at Lidl.”
(School 1)

Having the “right” education or the “right” job was seen as desirable, the “right” job being understood as a career requiring higher education or with a high salary in order to be of high status. Participants discussed experiences of feeling the need to carry on the family reputation and be able to take care of your parents in the future. A worry about the future was shared between the participants and much of this worry was discussed as related to parental pressure to do well in school in order reach a status position in the future.

The aim of this study was to explore young people’s experiences of equity in relation to everyday challenges, with a focus on race, gender, and socioeconomics. Among the participants, there was an awareness of social norms and inequities which they attempted to navigate. This awareness was due both to personal experiences and to observations of how others received rewards or punishments due to their race, gender, or what they could afford. Solidarity with others was expressed and participants discussed that you should not have to suffer from inequities, but that it still happened. Participants’ experiences related to socioeconomics, race, and gender were often discussed not separately but conjointly. For instance, gaining or losing status due to the right or wrong clothes was related not only to socioeconomics and being able to afford what was right, but also to gender, with a clear distinction between right or wrong for girls and boys, respectively.

Perspectives of race, gender, and socioeconomics were all present in the data, but socioeconomics was the dominating equity perspective recurring in the focus group discussions. Socioeconomic status is a commonly used background variable in health research and it is often defined by income or education level. For children, socioeconomic status is frequently measured by different combinations of parental socioeconomic status, such as parental income and education level (22). In this study, participants discussed their subjective understanding of their socioeconomic position and they often expressed socioeconomic status in very direct terms, with reference to having money or not. Being, or not being, able to afford certain things was something that had a big impact on the participants’ everyday life. This is supported by the findings of Ahlborg et al. (23), who found that subjective measures of socioeconomic status had a bigger impact on health inequalities than objective measures.

The navigation of equity-related factors is guided by social norms and expectations in the everyday life of the participants. Not living up to these social norms and expectations, due to yourself or your family background, results in negative consequences. Your background, your current position, and your hopes and fears about the future both affect and are affected by the losing and gaining of status. This aligns with previous research regarding social status and health which suggests that self-perceived low social status (24) and status-related shame (25) influence health and can contribute to explain the socioeconomic gradient in health (24, 26, 27).

Considering social status from a youth perspective, Joffer et al. (28) found, similar to this study, that young people were highly aware of their own status and that social factors such as gender, ethnicity, age, and parents’ financial situation influenced status, with boys, white people, older adolescents, and those whose parents had money, having a higher position in the social hierarchy. Girls also compared themselves to other girls to a greater extent than the boys compared themselves to other boys (28). The gender difference in comparing yourself when it comes to appearance and clothes was also experienced by participants in this study, although this finding was a bit inconclusive. On the one hand, girls were considered to care more about their appearance, but on the other hand, wearing the “right” designer label was considered more important for boys.

The result of this study shows that young people experience structural inequities in everyday life, something which, according to the ecosocial theory of disease distribution, affects health. Krieger (2021) states that the negative health consequences of this embodiment can be seen from a life-course and an intergenerational perspective. This ties in with the present study, where the background in terms of the socioeconomics, culture, and race of the parents affected the social status of the child. The result is also supported by previous research, such as, Bosma et al. (25) who found that childhood poverty was associated with feelings of shame in older adults and that childhood poverty had a stronger effect on shame than low adult socioeconomic status. Thus, potentially, your socioeconomic status while growing up continues to influence your self-image as an adult.

Methodological considerations

Performing a secondary analysis of previously conducted focus group discussions involves both limitations and strengths (18). The first author was not part of the data collection, which means that some nuances, for instance body language or group interaction that was not evident in the taped interviews, could have been missed. However, the second, third, and fourth author were involved in planning and conducting the focus group discussions. The participants were not asked directly about equity, race, gender, or socioeconomics, which is a limitation since it could mean that important experiences were missed. The fact that the discussions that took part happened spontaneously, based only on the encouragement to discuss everyday challenges, and were not guided by questions from the focus group moderators, could, however, be a strength.

The first author has previous experience of working with health equity issues and therefore has some preunderstanding, which could have influenced the analysis. This was balanced, however, by discussions with and input from the co-authors, who have experience of studies with a qualitative design and of studies about youth health. Three of the authors participated in the data collection and two did not, and this meant that different perspectives on the data could be taken.

More girls and students from school areas with good socioeconomic conditions participated in the focus groups, which could have affected the results. The race or ethnicity of the participants was not collected. The skewed sample could be a limitation for the study as well as not knowing the race of the participants. However, collecting information about race could be sensitive and difficult to find acceptance for in a Swedish cultural setting. Moreover, the fact that the gender of the participants was assumed and not asked of the participants could be a weakness, as some participants may not identify themselves with the assumed gender.

Qualitative content analysis was considered an appropriate method of analysis for this study, as it focuses on what the participants are saying, aiming to stay close to the data (20). The codes arrived at were kept close to the way the participants discussed the different issues but still had a certain level of interpretation, while the sub-themes, themes, and main theme had a higher level of interpretation and abstraction (29). The qualitative content analysis meant that the focus was not on how the participants spoke of the issues discussed but on what they had to say. Further, the aim was both to find what the text said, the manifest content, and what it talked about, the latent content (20).

Describing the process of content analysis is important in order to enable an evaluation of the study’s trustworthiness. Elo et al. (30) discuss trustworthiness in the different stages of qualitative content analysis, including the preparation, organization, and reporting of results. Preparation includes data collection but also choosing the unit of analysis. This study selected the unit of analysis deductively, through a theoretical framework. The advantages of this procedure, from a trustworthiness perspective, could be that the process of selecting the unit of analysis is more transparent and clearer to the reader. A disadvantage could be that potential data that would fit the aim but not the theory is disregarded. Presenting the organization phase in a clear way could be challenging, as it is not straightforward but rather a back-and-forth process. On the other hand, this back-and-forth process is necessary for the analysis, and a description of the steps can still be provided. The process of data organization included going back to the transcripts of the focus group discussions to ensure that the analysis captured what was said and talked about by the participants. This step of the analysis also encompassed discussing the codes, sub-themes, and themes with all of the authors. A way of ensuring trustworthiness in reporting the results could be to show the participants’ voices by including quotations from all the focus groups, which we have done.

Young people identify equity issues related to race, gender, and socioeconomics in their everyday life, also when not asked specifically about this but spontaneously in discussions of everyday challenges in general. Passing or not passing norms and expectations related to these issues is a way to lose and gain status in a school setting. The perspective of inequity was more present than an equity perspective in the focus group discussions, with socioeconomic inequities being the dominating inequity experience. Inequities due to socioeconomics are discussed in direct terms, as having money or not, which also results in direct consequences, such as not being able to join friends for activities due to cost. These experiences align with the ecosocial theory of disease distribution, as the effects of injustice on a concrete level affect people’s life. This is also important to consider in youth mental health promotion if the aim is to reduce health inequities. Further research is needed on young people’s everyday experiences of equity and how inequities, with an emphasis on socioeconomic inequities, affect their everyday challenges.

Authors
Helena Gard [email protected]
Karin Enskär [email protected]
Karin Ingvarsdotter [email protected]
Gabriella E. Isma [email protected]
Elisabeth Mangrio [email protected]

Ethical approval and consent to participate
The young people and their legal guardians received information about the study, and what participation would entail, before data collection. Informed consent was obtained from all participants before data collection, and for participants under the age of 15 informed consent was also obtained from legal guardians. The study was conducted following the ethical principles set out in the Declaration of Helsinki (31) and by the Swedish Ethics Review Board. The study has been approved by the Swedish Ethical Review Authority (reg.no. 2019-06430 / 2020-04-07).

Availability of data and materials
The results presented in this study are based on youth participation, and data material in the form of recordings or transcripts of focus group discussions cannot be made available for privacy reasons. In accordance with national legislation, the Swedish Ethical Review Authority does not allow release of sensitive raw data to the general public. Excerpts from the focus group discussions have been translated and are a part of the results as quotations.

Competing interests
The authors declare that they have no competing interests.

Consent for publication
Not applicable.

Funding
Funding for this study was provided by Faculty of Health and Society, Malmö university.

Authors' contributions
The data collection was managed by KE, KI, and GEI. HG conducted the analysis and drafted the whole manuscript with input from the other authors. KE, KI, GEI, and EM participated in the critical revision of the manuscript, provided important intellectual input, and all authors approved the final version of the manuscript.

Acknowledgements
The authors would like to thank the participants in the study and staff at participating schools.

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No competing interests reported.

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Exploring young people’s experiences of equity in relation to everyday challenges: a focus group study

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