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366 J. K. Vikan et al. of being comfortable addressing sexuality with patients and their partners (Table V). The entire model was statistically significant: χ 2 (7, n = 289) = 74.6, p < 0.001. DISCUSSION Lack of sexual health policy: A barrier to addressing sexuality These results indicate that a lack of sexual health policy represents a barrier to evidence-based practice in this area during stroke rehabilitation. A considerable varia- tion in sexual health policies was found between the 9 participating centres; being completely absent in some cases and sparse in most. At centres with high policy score, HCPs’ responses were consistently more positive about having routines and resources concerning sexual health at their workplace than at low-scoring centres. Thus, responses from HCPs are in accordance with the responses given by administrative leaders regarding their stroke rehabilitation unit’s sexual health policy. These findings suggest that lack of sexual health po- licy leaves HCPs without guidance and with undefined roles and responsibilities when addressing sexuality in clinical practice, allowing disclaim of responsibility among members of the rehabilitation team. The Austra- lian SOX study produced similar results, showing that employees were uncertain about their responsibility, underpinning the need for an interdisciplinary approach to addressing sexuality after stroke (24, 28). Based on their recent review of the literature, Grenier-Genest and colleagues recommended an interdisciplinary approach to sexuality in stroke rehabilitation to meet the complex impact of stroke on sexual wellbeing (8). However, results from the present study indicate a lack of interdisciplinary approach to sexuality in the majority of participants, as only one-fifth of HCPs indicated that addressing sexuality should be a mutual responsibility of the interdisciplinary team, and less than one-tenth reported such practice at their workplace. The fact that healthcare services, to a large extent, do not follow recommendations on implementing sexual health in standard care (1–6) is concerning. One possible explanation for these recommendations not being followed may be the lack of specific advice in guideline documents and the sparsity of studies on how to manage practice and clinical care with respect to sexual health. Stroke guidelines recommend that pa- tients and/or partners should be offered education and the opportunity to discuss sexuality with a healthcare provider, but they are not specific in defining roles or responsibility, and are limited regarding stroke-specific interventions for sexual problems or dysfunctions. Not having access to practical guidelines, educa- tion and training can also influence HCPs’ ability to www.medicaljournals.se/jrm address sexuality at an individual level. The present study shows that HCPs working at centres with high sexual health policy scores felt more comfortable with and more knowledgeable about sexual health issues than personnel at low-scoring centres. These findings are consistent with findings from qualitative studies of stroke and sexuality that describe a lack of policy as a barrier to HCPs initiating sexuality-related com- munication (20, 21). Policies on sexual health should therefore be designed in a proper way to be successful for use in clinical practice. This means taking into ac- count needs at an organizational and individual level to facilitate having this topic raised and handled in accordance with evidence-based practice. The po- licies should provide specific recommendations for information and interventions on sexual rehabilitation after stroke to guide clinicians. Cooperation with user organizations, user consultants and other stakeholders is a key to ensure patient experiences and involvement in development of recommendations. The capacity and ability of hospitals or organizations to prioritize sexual health may also be a question of economy and hospital facilities as well as staff resources. Policies on sexual health therefore need to be rooted in health authorities for successful sexual health promotion. Perceived low level of knowledge: A barrier to be overcome Importantly, more than three-quarters of HCPs in this study reported having little or no knowledge about working with sexual health after stroke. Similar findings have been reported by others (8, 17, 20, 21) as one of the major barriers to provide information about sexuality to patients and their partners. Most HCPs expressed a need for knowledge within several areas of sexual medicine/ sexology and preferred an interdisciplinary model for sexological education and training. It has been suggested that expertise may not be necessary when addressing sexuality, but emphasized the importance of strengthen­ ing communication skills (21). Results from the present study indicate that sexual health education is desired in order to support knowledge and comfort in HCPs. Given the complexity of the impact of stroke and the diversity of sexual problems, we believe that expertise should be available in the interdisciplinary team. The need for training and education in sexual health among all professions is emphasized by others (8). Perceived lack of knowledge is a barrier that can be overcome by supporting the correct education and training in sexual health. However, the ability and opportunity to change practice is more complex, being influenced by multi- ple interacting factors, including hospital policies as described, as well as social and cultural circumstances and personal level of comfort (12, 21).