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  • 1.
    Ekstrand Ragnar, Maria
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research.
    Grandahl, Maria
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research.
    Stern, Jenny
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. Sophiahemmet Univ, Dept Hlth Promoting Sci, Stockholm, Sweden.
    Mattebo, Magdalena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research. Malardalen Univ, Sch Hlth Care & Social Welf, Vasteras, Sweden.
    Important but far away: adolescents' beliefs, awareness and experiences of fertility and preconception health2018In: European journal of contraception & reproductive health care, ISSN 1362-5187, E-ISSN 1473-0782, Vol. 23, no 4, p. 265-273Article in journal (Refereed)
    Abstract [en]

    Objectives: The aim was to explore adolescents' beliefs and awareness regarding fertility and preconception health, as well as their views and experiences of information about fertility and preconception health directed at their age group.

    Methods: We performed seven semi-structured focus group interviews among upper secondary school students (n = 47) aged 16-18 years in two Swedish counties. Data were analysed by qualitative content analysis.

    Results: One theme ('important but far away') and five categories ('starting a family far down on the list'; 'high awareness but patchy knowledge of fertility and preconception health'; 'gender roles influence beliefs about fertility and preconception health'; 'wish to preserve fertility and preconception health in order to keep the door to procreation open'; 'no panacea - early and continuous education about fertility and preconception health') emerged from the interviews. Participants recognised the importance of preconception health and were highly aware of the overall importance of a healthy lifestyle. Their knowledge, however, was patchy and they had difficulties relating to fertility and preconception health on a personal and behavioural level. Participants wanted more information but had heterogeneous beliefs about when, where and how this information should be given.

    Conclusion: The adolescents wanted information on fertility and preconception health to be delivered repeatedly as well as through different sources.

  • 2.
    Gottvall, Maria
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Grandahl, Maria
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Höglund, Anna T.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Centre for Research Ethics and Bioethics.
    Larsson, Margareta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Stenhammar, Christina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Andrae, Bengt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Research and Development, Gävleborg.
    Tydén, Tanja
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Trust versus concerns: how parents reason when they accept HPV vaccination for their young daughter2013In: Upsala Journal of Medical Sciences, ISSN 0300-9734, E-ISSN 2000-1967, Vol. 118, no 4, p. 263-270Article in journal (Refereed)
    Abstract [en]

    Background. From spring of 2012, human papillomavirus (HPV) vaccine against cervical cancer is offered free of charge to all girls aged 10-12 years through a school-based vaccination programme in Sweden. The aim of this study was to explore how parents reason when they accept HPV vaccination for their young daughter and also their views on HPV-related information. Methods. Individual interviews with parents (n = 27) of 11-12-year-old girls. The interviews were recorded, transcribed verbatim, and analysed using thematic content analysis. Results. Three themes emerged through the analysis: Trust versus concern, Responsibility to protect against severe disease, and Information about HPV and HPV vaccination is important. The parents expressed trust in recommendations from authorities and thought it was convenient with school-based vaccination. They believed that cervical cancer was a severe disease and felt a responsibility to protect their daughter from it. Some had certain concerns regarding side effects and vaccine safety, and wished for a dialogue with the school nurse to bridge the information gaps. Conclusions. Trust in the recommendations from authorities and a wish to protect their daughter from a severe disease outweighed concerns about side effects. A school-based vaccination programme is convenient for parents, and the school nurse has an important role in bridging information gaps. The findings from this qualitative study cannot be generalized; however, it can provide a better understanding of how parents might reason when they accept the HPV vaccination for their daughter.

  • 3.
    Gottvall, Maria
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Clinical Psychology in Healthcare. Red Cross University College, Huddinge, Sweden.
    Stenhammar, Christina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Grandahl, Maria
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Parents' views of including young boys in the Swedish national school-based HPV vaccination programme: a qualitative study2017In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 7, no 2, article id e014255Article in journal (Refereed)
    Abstract [en]

    Objective: To explore parents' views of extending the human papillomavirus (HPV) vaccination programme to also include boys. Design: Explorative qualitative design using individual, face-to-face, interviews and inductive thematic analysis. Setting: 11 strategically chosen municipalities in central Sweden. Participants: Parents (n= 42) who were offered HPV vaccination for their 11-12 years old daughter in the national school-based vaccination programme. Results: The key themes were: equality from a public health perspective and perception of risk for disease. Parents expressed low knowledge and awareness about the health benefits of male HPV vaccination, and they perceived low risk for boys to get HPV. Some parents could not see any reason for vaccinating boys. However, many parents preferred gender-neutral vaccination, and some of the parents who had not accepted HPV vaccination for their daughter expressed that they would be willing to accept vaccination for their son, if it was offered. It was evident that there was both trust and distrust in authorities' decision to only vaccinate girls. Parents expressed a preference for increased sexual and reproductive health promotion such as more information about condom use. Some parents shared that it was more important to vaccinate girls than boys since they believed girls face a higher risk of deadly diseases associated with HPV, but some also believed girls might be more vulnerable to side effects of the vaccine. Conclusions: A vaccine offered only to girls may cause parents to be hesitant to vaccinate, while also including boys in the national vaccination programme might improve parents' trust in the vaccine. More information about the health benefits of HPV vaccination for males is necessary to increase HPV vaccination among boys. This may eventually lead to increased HPV vaccine coverage among both girls and boys.

  • 4.
    Grandahl, Maria
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Prevention of Human Papillomavirus in a school-based setting2015Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The overall aim of this thesis was to examine beliefs about human papillomavirus (HPV) prevention, especially vaccination, among parents, immigrant women, adolescents and school nurses, and to promote primary prevention among adolescents.

    The methods used in the thesis were focus group interviews, individual interviews, a web-based questionnaire, and finally, a randomised controlled intervention study.

    The immigrant women were largely in favour of HPV prevention, although barriers, such as logistic difficulties, and cultural or gender norms were found. Parents’ decision concerning vaccination of their daughters depended on several factors. Regardless of their final choice, they made the decision they believed was in the best interest of their daughter. The benefits outweighed the risks for parents choosing to vaccinate while parents declining made the opposite judgement. The majority of the school nurses reported that the governmental financial support given because of the vaccination programme had not been used for the intended purpose. Three out of four nurses had been contacted by parents who raised questions regarding the vaccine; most were related to side effects. The educational intervention had favourable effects on the adolescents’ beliefs regarding HPV prevention, especially among those with an immigrant background. Furthermore, the intention to use condom as well as actual vaccination rates among girls was slightly increased by the intervention.

    Trust in the governmental recommendations and the amounts of information given are important factors in the complex decision about HPV vaccination. Attention given to specific needs and cultural norms, as well as the possibility to discuss HPV vaccination with the school nurse and provision of extra vaccination opportunities at a later time are all strategies that might facilitate participation in the school-based HPV vaccination programme. School nurses need sufficient resources, knowledge and time to meet parents’ questions and concerns. The vaccinations are time-consuming and the governmental financial support needs to be used as intended, for managing the vaccination programme. A school-based intervention can have favourable effects on the beliefs and actual actions of young people and may possibly thus, in the long term, decrease the risk for HPV-related cancer.

    List of papers
    1. Immigrant women’s experiences and views on the prevention of cervical cancer: a qualitative study
    Open this publication in new window or tab >>Immigrant women’s experiences and views on the prevention of cervical cancer: a qualitative study
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    2015 (English)In: Health Expectations, ISSN 1369-6513, E-ISSN 1369-7625, Vol. 18, no 3, p. 344-354Article in journal (Refereed) Published
    Abstract [en]

    Background

    Many Western countries have cervical cancer screening programmes and have implemented nation-wide human papillomavirus (HPV) vaccination programmes for preventing cervical cancer.

    Objective

    To explore immigrant women's experiences and views on the prevention of cervical cancer, screening, HPV vaccination and condom use.

    Design

    An exploratory qualitative study. The Health Belief Model (HBM) was used as a theoretical framework.

    Setting and participants

    Eight focus group interviews, 5–8 women in each group (average number 6,5), were conducted with 50 women aged 18–54, who studied Swedish for immigrants. Data were analysed by latent content analysis.

    Results

    Four themes emerged: (i) deprioritization of women's health in home countries, (ii) positive attitude towards the availability of women's health care in Sweden, (iii) positive and negative attitudes towards HPV vaccination, and (iv) communication barriers limit health care access. Even though the women were positive to the prevention of cervical cancer, several barriers were identified: difficulties in contacting health care due to language problems, limited knowledge regarding the relation between sexual transmission of HPV and cervical cancer, culturally determined gender roles and the fact that many of the women were not used to regular health check-ups.

    Conclusion

    The women wanted to participate in cervical cancer prevention programmes and would accept HPV vaccination for their daughters, but expressed difficulties in understanding information from health-care providers. Therefore, information needs to be in different languages and provided through different sources. Health-care professionals should also consider immigrant women's difficulties concerning cultural norms and pay attention to their experiences.

    National Category
    Public Health, Global Health, Social Medicine and Epidemiology
    Identifiers
    urn:nbn:se:uu:diva-166329 (URN)10.1111/hex.12034 (DOI)000353956900006 ()23252449 (PubMedID)
    Available from: 2012-01-11 Created: 2012-01-11 Last updated: 2019-10-18Bibliographically approved
    2. Trust versus concerns: how parents reason when they accept HPV vaccination for their young daughter
    Open this publication in new window or tab >>Trust versus concerns: how parents reason when they accept HPV vaccination for their young daughter
    Show others...
    2013 (English)In: Upsala Journal of Medical Sciences, ISSN 0300-9734, E-ISSN 2000-1967, Vol. 118, no 4, p. 263-270Article in journal (Refereed) Published
    Abstract [en]

    Background. From spring of 2012, human papillomavirus (HPV) vaccine against cervical cancer is offered free of charge to all girls aged 10-12 years through a school-based vaccination programme in Sweden. The aim of this study was to explore how parents reason when they accept HPV vaccination for their young daughter and also their views on HPV-related information. Methods. Individual interviews with parents (n = 27) of 11-12-year-old girls. The interviews were recorded, transcribed verbatim, and analysed using thematic content analysis. Results. Three themes emerged through the analysis: Trust versus concern, Responsibility to protect against severe disease, and Information about HPV and HPV vaccination is important. The parents expressed trust in recommendations from authorities and thought it was convenient with school-based vaccination. They believed that cervical cancer was a severe disease and felt a responsibility to protect their daughter from it. Some had certain concerns regarding side effects and vaccine safety, and wished for a dialogue with the school nurse to bridge the information gaps. Conclusions. Trust in the recommendations from authorities and a wish to protect their daughter from a severe disease outweighed concerns about side effects. A school-based vaccination programme is convenient for parents, and the school nurse has an important role in bridging information gaps. The findings from this qualitative study cannot be generalized; however, it can provide a better understanding of how parents might reason when they accept the HPV vaccination for their daughter.

    Keywords
    Decision-making, HPV vaccination, parents, school-based vaccination, school nurses
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-210566 (URN)10.3109/03009734.2013.809039 (DOI)000325527300009 ()23777602 (PubMedID)
    Note

    De två första författarna delar förstaförfattarskapet.

    Available from: 2013-11-13 Created: 2013-11-11 Last updated: 2019-10-18Bibliographically approved
    3. Not the right time: why parents refuse to let their daughters have the human papillomavirus vaccination
    Open this publication in new window or tab >>Not the right time: why parents refuse to let their daughters have the human papillomavirus vaccination
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    2014 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 103, no 4, p. 436-441Article in journal (Refereed) Published
    Abstract [en]

    Aim: To explore why parents refused to allow their 10- to 12-year-old daughters to receive the human papillomavirus (HPV) vaccination from the Swedish school-based vaccination programme.

    Methods: Individual interviews with 25 parents who had been offered, but not consented to, their daughters receiving the HPV vaccination.

    Results: Five themes emerged through the interviews: 1) she is just a little girl, 2) inadequate information, 3) not compatible with our way of life, 4) scepticism about the vaccination and 5) who can you trust? The parents made their decisions with their child’s best interests in mind. This was not considered the right time, and the vaccine as perceived as unnecessary and different from other vaccines. Mistrust in Government recommendations and a lack of evidence or information were other reasons to decline.

    Conclusion: The decision-making process was complex. These parents preferred to wait until their daughter was older and believed the information they received from the school health system was insufficient. The results indicate that a more flexible HPV vaccination schedule may improve vaccine uptake. This includes more transparent information about the virus and the vaccine and information about who to contact to get the daughter vaccinated at a later date.

    Keywords
    Decision-making, Human papillomavirus, Parents, School, Vaccination programmes
    National Category
    Public Health, Global Health, Social Medicine and Epidemiology
    Research subject
    Caring Sciences
    Identifiers
    urn:nbn:se:uu:diva-214970 (URN)10.1111/apa.12545 (DOI)000332694700025 ()
    Available from: 2014-01-09 Created: 2014-01-09 Last updated: 2019-10-18Bibliographically approved
    4. School nurses’ attitudes and experiences regarding the human papillomavirus vaccination programme in Sweden: a population-based survey
    Open this publication in new window or tab >>School nurses’ attitudes and experiences regarding the human papillomavirus vaccination programme in Sweden: a population-based survey
    Show others...
    2014 (English)In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 14, no 540, p. 1-9Article in journal (Refereed) Published
    Abstract [en]

    Background: Sweden introduced a school-based human papillomavirus (HPV) vaccination programme in 2012, andschool nurses are responsible for managing the vaccinations. The aim of the present study was to investigate theattitudes and experiences of school nurses regarding the school-based HPV vaccination programme 1 year after itsimplementation.Methods: Data were collected using a web-based questionnaire in the spring of 2013, and 83.1% (851/1024) ofnurses responded.Results: There were strong associations between the nurses’ education about the HPV vaccine and their perceivedknowledge about the vaccine and a favourable attitude towards vaccination (both p < 0.001). School nurses whoreceived a high level of education were more likely to have a positive attitude to HPV vaccination compared withnurses with little education about HPV vaccination (adjusted odds ratio [OR] = 9.8; 95% confidence interval [CI]:3.797–25.132). Nurses with high perceived knowledge were more likely to have a positive attitude compared withthose with a low level of perceived knowledge (OR = 2.5; 95% CI: 1.299–4.955). If financial support from thegovernment was used to fund an additional school nurse, nurses were more likely to have a positive attitude thanif the financial support was not used to cover the extra expenses incurred by the HPV vaccination (OR = 2.1; 95% CI:1.051–4.010). The majority, 648 (76.1%), had been contacted by parents with questions about the vaccine, mostlyrelated to adverse effects. In addition, 570 (66.9%) stated that they had experienced difficulties with thevaccinations, and 337 (59.1%) of these considered the task to be time-consuming.Conclusions: A high level of education and perceived good knowledge about HPV are associated with a positiveattitude of school nurses to the HPV vaccination programme. Thus, nurses require adequate knowledge, education,skills and time to address the questions and concerns of parents, as well as providing information about HPV.Strategic financial support is required because HPV vaccination is a complex and time-consuming task.

    Place, publisher, year, edition, pages
    BioMed Central, 2014
    Keywords
    Attitude, Experience, Human papillomavirus, School health, School nurse, Vaccination
    National Category
    Health Sciences
    Research subject
    Caring Sciences
    Identifiers
    urn:nbn:se:uu:diva-229189 (URN)10.1186/1471-2458-14-540 (DOI)000338959600002 ()24886332 (PubMedID)
    Funder
    Swedish Cancer Society, 130744
    Available from: 2014-08-05 Created: 2014-08-05 Last updated: 2019-10-18Bibliographically approved
    5. School-based intervention for the prevention of HPV among adolescents: a cluster randomised controlled study
    Open this publication in new window or tab >>School-based intervention for the prevention of HPV among adolescents: a cluster randomised controlled study
    Show others...
    2016 (English)In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 6, no 1, article id e009875Article in journal (Refereed) Published
    Abstract [en]

    Objective: To improve primary prevention of human papillomavirus (HPV) infection by promoting vaccination and increased condom use among upper secondary school students. Design: Cluster randomised controlled trial. Setting: 18 upper secondary schools in Sweden. Participants: Schools were first randomised to the intervention or the control group, after which individual classes were randomised so as to be included or not. Of the 832 students aged 16 years invited to participate during the regular individual health interview with the school nurse, 751 (90.2%) agreed to participate and 741 (89.1%) students completed the study. Interventions: The intervention was based on the Health Belief Model (HBM). According to HBM, a person's health behaviour can be explained by individual beliefs regarding health actions. School nurses delivered 30 min face-to-face structured information about HPV, including cancer risks and HPV prevention, by propagating condom use and HPV vaccination. Students in the intervention and the control groups completed questionnaires at baseline and after 3 months. Main outcome measures: Intention to use condom with a new partner and beliefs about primary prevention of HPV, and also specifically vaccination status and increased condom use. Results: All statistical analyses were performed at the individual level. The intervention had a significant effect on the intention to use condom (p=0.004). There was also a significant effect on HBM total score (p=0.003), with a 2.559 points higher score for the intervention group compared to the controls. The influence on the HBM parameters susceptibility and severity was also significant (p<0.001 for both variables). The intervention also influenced behaviour: girls in the intervention group chose to have themselves vaccinated to a significantly higher degree than the controls (p=0.02). No harms were reported. Conclusions: The school-based intervention had favourable effects on the beliefs about primary prevention of HPV, and increased the HPV vaccination rates in a diverse population of adolescents.

    Keywords
    adolescents, HPV, prevention, randomised control trial, school-based
    National Category
    Public Health, Global Health, Social Medicine and Epidemiology Obstetrics, Gynecology and Reproductive Medicine
    Identifiers
    urn:nbn:se:uu:diva-263257 (URN)10.1136/bmjopen-2015-009875 (DOI)000369993900136 ()
    Funder
    Swedish Cancer Society, 130744
    Available from: 2015-09-30 Created: 2015-09-29 Last updated: 2019-10-18Bibliographically approved
  • 5.
    Grandahl, Maria
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research.
    Larsson, Margareta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research.
    Dalianis, Tina
    Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
    Stenhammar, Christina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Tydén, Tanja
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research.
    Westerling, Ragnar
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Social Medicine.
    Nevéus, Tryggve
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Paediatric Inflammation Research.
    Catch-up HPV vaccination status of adolescents in relation to socioeconomic factors, individual beliefs and sexual behaviour2017In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 12, no 11, article id e0187193Article in journal (Refereed)
    Abstract [en]

    In 2012, human papillomavirus (HPV) vaccination was introduced free of charge in the Swedish national school-based vaccination programme for 10-12-year-old girls, and as catch-up vaccination for young women. In Sweden, there is an ongoing discussion about including boys in the national vaccination programme. Few studies are undertaken about adolescents' knowledge, beliefs and HPV vaccination status in relation to socioeconomic status and sexual experience. Thus, the aim was to examine HPV catch-up vaccination status in adolescents in relation to 1) socioeconomic factors, 2) beliefs and knowledge about HPV prevention, and 3) sexual behaviour. The Health Belief Model was used as a theoretical framework. Upper secondary school students (n = 832) aged 16, randomly chosen from a larger sample, were invited to participate in conjunction with the general health interview with the school nurse. A total of 751/832 (90.3%), girls (n = 391, 52%) and boys (n = 360, 48%) completed the questionnaire. HPV vaccination was associated with ethnicity and the mothers' education level; i.e. girls with a non-European background and girls with a less educated mother were less likely to have received the vaccine (p<0.01 and p = 0.04 respectively). Vaccinated girls perceived HPV infection as more severe (p = 0.01), had more insight into women's susceptibility to the infection (p = 0.02), perceived more benefits of the vaccine as protection against cervical cancer (p<0.01) and had a higher intention to engage in HPV-preventive behaviour (p = 0.01). Furthermore, boys and girls were almost equally sexually experienced, although fewer girls had used condom during first intercourse with their latest partner (p = 0.03). Finally, HPV vaccinated girls were less likely to have unprotected sex (p<0.01). In summary, catch-up HPV vaccination among young girls was associated with a European background and high maternal education level, as well as more favourable beliefs towards HPV prevention and less sexual risk-taking. Further preventive measures should therefore be directed at the migrant population.

  • 6.
    Grandahl, Maria
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Larsson, Margareta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Tydén, Tanja
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Stenhammar, Christina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    School nurses' attitudes towards and experiences of the Swedish school-based HPV vaccination programme - A repeated cross sectional study2017In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 12, no 4, article id e0175883Article in journal (Refereed)
    Abstract [en]

    The aim was to investigate school nurses' attitudes towards, and experiences of vaccination against human papillomavirus (HPV), and compare the results with a similar study three years earlier. School nurses (n = 736) from all counties in Sweden completed a questionnaire in spring 2016, four years after the implementation of the national HPV vaccination programme, and three years after the previous survey. Overall, the school nurses had more favourable attitudes towards the HPV vaccination programme compared to the study in 2013 (p = 0.015). More than half of the nurses (n = 415, 56%) strongly agreed that boys should also be offered the vaccine (p<0.001). There were no differences in school nurses' perceived knowledge about HPV in order to inform and to answer questions about the vaccine from the girls or from the parents. More than half of the nurses (n = 409, 56%) reported that they needed more education about HPV. Almost all nurses (n = 659, 90%) had been contacted by parents with questions about the vaccine, and most questions were related to vaccine safety. School nurses have a more favourable attitude towards the vaccination programme against HPV compared to three years earlier, although almost all nurses had been contacted by parents with diverse questions and concerns. The nurses believed that they needed more education about HPV. Thus, it is essential to provide ongoing education and training for school nurses who are key healthcare professionals for providing information about HPV and HPV vaccination to parents and to pupils.

  • 7.
    Grandahl, Maria
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research.
    Nevéus, Tryggve
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Paediatric Inflammation, Metabolism and Child Health Research.
    Dalianis, Tina
    Karolinska Inst, Karolinska Univ Hosp, Dept Oncol Pathol, Stockholm, Sweden.
    Larsson, Margareta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research.
    Tydén, Tanja
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research.
    Stenhammar, Christina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research.
    ‘I also want to be vaccinated!’ – adolescent boys’ awareness and thoughts, perceived benefits, information sources, and intention to be vaccinated against Human papillomavirus (HPV)2019In: Human Vaccines & Immunotherapeutics, ISSN 2164-5515, E-ISSN 2164-554X, Vol. 15, no 7-8, p. 1794-1802Article in journal (Refereed)
    Abstract [en]

    This study investigates boys’ awareness and thoughts about human papillomavirus (HPV) and HPV vaccination, perceived benefits of vaccinating men, information sources and intention to be vaccinated against HPV. We used a qualitative approach and interviews were conducted with 31 upper secondary school male students. Two main themes 1) Promotion of equal health and 2) Increased knowledge facilitates the decision about HPV vaccination emerged from the analysis. The informants believed that it was important and fair to protect boys and girls equally against HPV. If HPV vaccination could prevent both girls and boys against an HPV-related disease, there was nothing to question or to discuss. It was not a matter of sex; it was a matter of equal rights. Moreover, an important reason for vaccinating boys was to prevent the transmission of the virus. However, the boys felt unsure and stated that they needed to know more. The school nurse and the school health were considered suitable both for distributing information and for providing the vaccinations.

    In conclusion, the participants were in favor of introducing HPV vaccination also for boys in the national vaccination program. Sex-neutral HPV vaccinations were viewed both as a way to stop the virus transmission and a means to promote equal health for the entire population.

  • 8.
    Grandahl, Maria
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Oscarsson, Marie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences. Linnéuniversitetet.
    Stenhammar, Christina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Nevéus, Tryggve
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Pediatrics.
    Westerling, Ragnar
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Social Medicine.
    Tydén, Tanja
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Not the right time: why parents refuse to let their daughters have the human papillomavirus vaccination2014In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 103, no 4, p. 436-441Article in journal (Refereed)
    Abstract [en]

    Aim: To explore why parents refused to allow their 10- to 12-year-old daughters to receive the human papillomavirus (HPV) vaccination from the Swedish school-based vaccination programme.

    Methods: Individual interviews with 25 parents who had been offered, but not consented to, their daughters receiving the HPV vaccination.

    Results: Five themes emerged through the interviews: 1) she is just a little girl, 2) inadequate information, 3) not compatible with our way of life, 4) scepticism about the vaccination and 5) who can you trust? The parents made their decisions with their child’s best interests in mind. This was not considered the right time, and the vaccine as perceived as unnecessary and different from other vaccines. Mistrust in Government recommendations and a lack of evidence or information were other reasons to decline.

    Conclusion: The decision-making process was complex. These parents preferred to wait until their daughter was older and believed the information they received from the school health system was insufficient. The results indicate that a more flexible HPV vaccination schedule may improve vaccine uptake. This includes more transparent information about the virus and the vaccine and information about who to contact to get the daughter vaccinated at a later date.

  • 9.
    Grandahl, Maria
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research. Uppsala Univ, Dept Womens & Childrens Hlth, Uppsala, Sweden..
    Paek, Seung Chun
    Mahidol Univ, Dept Soc & Hlth, Salaya Campus, Bangkok, Thailand..
    Grisurapong, Siriwan
    Mahidol Univ, Dept Soc & Hlth, Salaya Campus, Bangkok, Thailand..
    Sherer, Penchan
    Mahidol Univ, Dept Soc & Hlth, Salaya Campus, Bangkok, Thailand..
    Tydén, Tanja
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Research group (Dept. of women´s and children´s health), Obstetrics and Reproductive Health Research. Uppsala Univ, Dept Womens & Childrens Hlth, Uppsala, Sweden..
    Lundberg, Pranee
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Parents' knowledge, beliefs, and acceptance of the HPV vaccination in relation to their socio-demographics and religious beliefs: A cross-sectional study in Thailand2018In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 13, no 2, article id e0193054Article in journal (Refereed)
    Abstract [en]

    Thailand has one of the world's highest prevalence of cervical cancer, mainly caused by the human papillomavirus (HPV). HPV infections can successfully be prevented by vaccination, which is available at a cost but not yet implemented in the national vaccination program. Parents play a critical role in deciding whether to vaccinate their child against HPV. Thus, the aim was to examine the association between parents' knowledge, beliefs, and acceptance of the HPV vaccination for their daughters, considering their socio-demographics and religious beliefs. A cross-sectional design was used among three schools in Thailand: Nakorn Phatom province (suburban) and Bangkok (urban). Parents of 9-12-year-old daughters completed the questionnaires, guided by the Health Belief Model. In total, 359 parents completed the questionnaires; of those, 301 were included in the final analyses. The ordinary least squares (OLS) regression analysis showed that background knowledge of HPV and the HPV vaccine was positively related to knowledge of HPV and cervical cancer. For beliefs, knowledge was positively associated with susceptibility (i.e., parents' perceived risk of an HPV infection/related disease), severity, and benefit. However, knowledge was not significantly related to barriers. For acceptance, higher susceptibility and benefit were related to higher acceptance, and greater knowledge was associated with higher acceptance. Thus, we found associations between parents' knowledge, beliefs, and acceptance of the HPV vaccination for their daughters, considering their socio-demographics and religious beliefs. Parents, who reported religion as important, as opposed to those who did not, were more favorable toward the HPV vaccination. Four out of ten mothers had never undergone a cervical cancer screening, but most had accepted previous childhood vaccinations for their daughters. The overall acceptance of the vaccine was high, and we believe our results are promising for future implementation of the HPV vaccination in the national childhood vaccination program in Thailand.

  • 10.
    Grandahl, Maria
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Rosenblad, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Stenhammar, Christina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Tydén, Tanja
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Westerling, Ragnar
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Social Medicine.
    Larsson, Margareta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Oscarsson, Marie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Andrae, Bengt
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Research and Development, Gävleborg.
    Dalianis, Tina
    Neveus, Tryggve
    School-based intervention for the prevention of HPV among adolescents: a cluster randomised controlled study2016In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 6, no 1, article id e009875Article in journal (Refereed)
    Abstract [en]

    Objective: To improve primary prevention of human papillomavirus (HPV) infection by promoting vaccination and increased condom use among upper secondary school students. Design: Cluster randomised controlled trial. Setting: 18 upper secondary schools in Sweden. Participants: Schools were first randomised to the intervention or the control group, after which individual classes were randomised so as to be included or not. Of the 832 students aged 16 years invited to participate during the regular individual health interview with the school nurse, 751 (90.2%) agreed to participate and 741 (89.1%) students completed the study. Interventions: The intervention was based on the Health Belief Model (HBM). According to HBM, a person's health behaviour can be explained by individual beliefs regarding health actions. School nurses delivered 30 min face-to-face structured information about HPV, including cancer risks and HPV prevention, by propagating condom use and HPV vaccination. Students in the intervention and the control groups completed questionnaires at baseline and after 3 months. Main outcome measures: Intention to use condom with a new partner and beliefs about primary prevention of HPV, and also specifically vaccination status and increased condom use. Results: All statistical analyses were performed at the individual level. The intervention had a significant effect on the intention to use condom (p=0.004). There was also a significant effect on HBM total score (p=0.003), with a 2.559 points higher score for the intervention group compared to the controls. The influence on the HBM parameters susceptibility and severity was also significant (p<0.001 for both variables). The intervention also influenced behaviour: girls in the intervention group chose to have themselves vaccinated to a significantly higher degree than the controls (p=0.02). No harms were reported. Conclusions: The school-based intervention had favourable effects on the beliefs about primary prevention of HPV, and increased the HPV vaccination rates in a diverse population of adolescents.

  • 11.
    Grandahl, Maria
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Tyden, Tanja
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Gottvall, Maria
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Westerling, Ragnar
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Social Medicine.
    Oscarsson, Marie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Immigrant women’s experiences and views on the prevention of cervical cancer: a qualitative study2015In: Health Expectations, ISSN 1369-6513, E-ISSN 1369-7625, Vol. 18, no 3, p. 344-354Article in journal (Refereed)
    Abstract [en]

    Background

    Many Western countries have cervical cancer screening programmes and have implemented nation-wide human papillomavirus (HPV) vaccination programmes for preventing cervical cancer.

    Objective

    To explore immigrant women's experiences and views on the prevention of cervical cancer, screening, HPV vaccination and condom use.

    Design

    An exploratory qualitative study. The Health Belief Model (HBM) was used as a theoretical framework.

    Setting and participants

    Eight focus group interviews, 5–8 women in each group (average number 6,5), were conducted with 50 women aged 18–54, who studied Swedish for immigrants. Data were analysed by latent content analysis.

    Results

    Four themes emerged: (i) deprioritization of women's health in home countries, (ii) positive attitude towards the availability of women's health care in Sweden, (iii) positive and negative attitudes towards HPV vaccination, and (iv) communication barriers limit health care access. Even though the women were positive to the prevention of cervical cancer, several barriers were identified: difficulties in contacting health care due to language problems, limited knowledge regarding the relation between sexual transmission of HPV and cervical cancer, culturally determined gender roles and the fact that many of the women were not used to regular health check-ups.

    Conclusion

    The women wanted to participate in cervical cancer prevention programmes and would accept HPV vaccination for their daughters, but expressed difficulties in understanding information from health-care providers. Therefore, information needs to be in different languages and provided through different sources. Health-care professionals should also consider immigrant women's difficulties concerning cultural norms and pay attention to their experiences.

  • 12.
    Grandahl, Maria
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Tydén, Tanja
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Rosenblad, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Oscarsson, Marie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Nevéus, Tryggve
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Pediatrics.
    Stenhammar, Christina
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    School nurses’ attitudes and experiences regarding the human papillomavirus vaccination programme in Sweden: a population-based survey2014In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 14, no 540, p. 1-9Article in journal (Refereed)
    Abstract [en]

    Background: Sweden introduced a school-based human papillomavirus (HPV) vaccination programme in 2012, andschool nurses are responsible for managing the vaccinations. The aim of the present study was to investigate theattitudes and experiences of school nurses regarding the school-based HPV vaccination programme 1 year after itsimplementation.Methods: Data were collected using a web-based questionnaire in the spring of 2013, and 83.1% (851/1024) ofnurses responded.Results: There were strong associations between the nurses’ education about the HPV vaccine and their perceivedknowledge about the vaccine and a favourable attitude towards vaccination (both p < 0.001). School nurses whoreceived a high level of education were more likely to have a positive attitude to HPV vaccination compared withnurses with little education about HPV vaccination (adjusted odds ratio [OR] = 9.8; 95% confidence interval [CI]:3.797–25.132). Nurses with high perceived knowledge were more likely to have a positive attitude compared withthose with a low level of perceived knowledge (OR = 2.5; 95% CI: 1.299–4.955). If financial support from thegovernment was used to fund an additional school nurse, nurses were more likely to have a positive attitude thanif the financial support was not used to cover the extra expenses incurred by the HPV vaccination (OR = 2.1; 95% CI:1.051–4.010). The majority, 648 (76.1%), had been contacted by parents with questions about the vaccine, mostlyrelated to adverse effects. In addition, 570 (66.9%) stated that they had experienced difficulties with thevaccinations, and 337 (59.1%) of these considered the task to be time-consuming.Conclusions: A high level of education and perceived good knowledge about HPV are associated with a positiveattitude of school nurses to the HPV vaccination programme. Thus, nurses require adequate knowledge, education,skills and time to address the questions and concerns of parents, as well as providing information about HPV.Strategic financial support is required because HPV vaccination is a complex and time-consuming task.

  • 13.
    Grandahl, Maria
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health.
    Tydén, Tanja
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Westerling, Ragnar
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Social Medicine.
    Nevéus, Tryggve
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Pediatrics.
    Rosenblad, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Hedin, Erik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences.
    Oscarsson, Marie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences. Department of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden..
    To Consent or Decline HPV Vaccination: A Pilot Study at the Start of the National School-Based Vaccination Program in Sweden2017In: Journal of School Health, ISSN 0022-4391, E-ISSN 1746-1561, Vol. 87, no 1, p. 62-70Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Parents' beliefs about human papillomavirus (HPV) vaccination influence whether they allow their daughters to be vaccinated. We examined the association between parents' refusal and sociodemographic background, knowledge and beliefs about HPV, and the HPV vaccination in relation to the Health Belief Model.

    METHODS:

    The sample consisted of 200 (55%) parents of children aged 11-12 years in the Swedish national vaccination program. Data were collected using a self-reported questionnaire. Most parents (N = 186) agreed to the vaccination. Pearson's chi-square, Fisher's exact test, and the Mann-Whitney U test were used to analyze data.

    RESULTS:

    Declining parents saw more risks and fewer benefits of HPV vaccination but no differences in beliefs regarding the severity or young girls' susceptibility to HPV were found. There was an association between refusing the HPV vaccine and lower acceptance of previous childhood vaccinations, and their main source of information was the Internet. Parents who declined the vaccine believed it could adversely affect condom use, the age of their daughter's sexual debut, and the number of sexual partners.

    CONCLUSION:

    Parents should have the possibility to discuss HPV and HPV vaccine with a school nurse or other health care professionals, and should have access to evidence-based information on the Internet.

  • 14.
    Stern, Jenny
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Bodin, Maja
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Grandahl, Maria
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Segeblad, Birgitta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Axen, L.
    Larsson, Margareta
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Obstetrics and Gynaecology.
    Tyden, Tanja
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Midwives' adoption of the reproductive life plan in contraceptive counselling: a mixed methods study2015In: Human Reproduction, ISSN 0268-1161, E-ISSN 1460-2350, Vol. 30, no 5, p. 1146-1155Article in journal (Refereed)
    Abstract [en]

    STUDY QUESTION: How is the reproductive life plan (RLP) adopted in midwifery contraceptive counselling? SUMMARY ANSWER: A majority of midwives adopted the RLP in their counselling, had predominantly positive experiences and considered it a feasible tool for promoting reproductive health. WHAT IS KNOWN ALREADY: The RLP is a health-promoting tool recommended by the Centers for Disease Control and Prevention in the USA for improving preconception health. It was recently used in a clinical setting in Sweden and was found to increase women's knowledge about fertility and to influence women's wishes to have their last child earlier in life. STUDY DESIGN, SIZE, DURATION: An exploratory mixed methods study among 68 midwives who provided contraceptive counselling in primary health care to at least 20 women each during the study period. Midwives received an introduction and materials for using the RLP in contraceptive counselling. Three months later, in the spring of 2014, they were invited to complete a questionnaire and participate in a focus group interview about their adoption of the RLP. PARTICIPANTS/MATERIALS, SETTING, METHODS: Data collection was through a questionnaire (n = 53 out of 68; participation rate 78%) and five focus group interviews (n = 22). Participants included both younger and older midwives with longer and shorter experiences of contraceptive counselling in public and private health care in one Swedish county. Quantitative data were analysed for differences between users and non-users, and qualitative data were analysed by qualitative content analysis to explore the midwives experiences and opinions of using the RLP. MAIN RESULTS AND THE ROLE OF CHANCE: Sixty-eight per cent of midwives had used the RLP in their contraceptive counselling. Four categories emerged through the focus group interviews: (i) A predominantly positive experience; (ii) The RLP-a health-promoting tool; (iii) individual and societal factors influence the RLP counselling; and (4) long-term implementation comprises opportunities, risks and needs. The most common reason for not using the RLP was lack of information. LIMITATIONS, REASONS FOR CAUTION: There was general lack of experience of using the RLP with women from different cultural backgrounds, with non-Swedish speaking women and, when a partner was present. Due to the non-random sample, the limited knowledge about non-responders and a short follow-up period, results apply to short-term implementations and might not fully apply to long-term implementation. WIDER IMPLICATIONS OF THE FINDINGS: The use of RLP in contraceptive counselling appears a feasible way of promoting reproductive health. Results from the USA and Sweden indicate it is a promising tool for midwives and other health professionals involved in reproductive counselling, which deserves to be explored in other nations.

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