Sexual health policies in stroke rehabilitation
Perceived low level of comfort: a multifactorial barrier
A majority of HCPs in the present study felt uncomfort
able providing information about sexuality to patients
and their partners. Personal level of comfort is described
as an important factor in addressing sensitive topics, with
personal life experiences, personality and workplace
environment potentially playing a significant role (21).
The impact of patient’s gender, age and marital status
on level of comfort could preferably be explored with
respect to possible societal or cultural differences. Ge-
neral assumptions have been described about elderly
people and people with disabilities as asexual (21,
29). Training focusing on the diversity of sexuality
throughout all stages of life might help to produce a
more open-minded approach in stroke rehabilitation.
Cultural sensitivity is necessary in order to ensure that
patients’ and partners’ rehabilitation needs are revealed
and dealt with in a respectful manner. Education for
staff and hospital policies should therefore take these
factors into account. For instance, the facilitation of
patients talking to HCPs of the same gender if this re-
presents a barrier to sexuality-related communication.
HCPs’ age and gender were not found to be associa-
ted with level of comfort addressing sexuality, while
those reporting a higher level of knowledge were more
likely to feel comfortable. This confirmed previous
studies describing knowledge as an important factor for
being comfortable (8, 21). Being employed at centres
scoring high on sexual health policy was also asso-
ciated with being comfortable addressing sexuality.
This interaction between individual level of comfort
and factors at an organizational level, such as hospital
policies, has been discussed in qualitative studies (20,
21). Richards et al. (21) developed a theoretical model
illustrating that the action taken by HCPs is influenced
by the interaction between their personal level of com-
fort and various barriers to addressing sexuality, such
as environmental barriers, personal skills and attitudes.
The more uncomfortable the HCPs, the more restricted
they are by such barriers. This model is useful in un-
derstanding the findings in the present study. If HCPs
feel uncomfortable addressing sexual health, the more
important it is to have hospital policies contributing to
strengthen their confidence and knowledge in doing so.
The differences in comfort among professions when
addressing sexuality support the need for interdisci-
plinary education and training among all professions,
strengthening confidence and skills at an individual
level, but also at an interdisciplinary level. However,
in order to facilitate making sexual health a natural part
of stroke rehabilitation, personal skills and knowledge
alone are not sufficient; organizational factors also
need to be considered.
In a qualitative study, Mellor et al. (20) described
sexuality as taboo among HCPs, who considered sexu-
367
ality a private matter that should only be raised by pa-
tients. Legitimizing sexuality as a part of rehabilitation
by implementing standard care procedures and routines
could therefore be significant in supporting the confi-
dence and comfort of employees and thus, meeting the
sexual rehabilitation needs of patients and their partners.
Strengths and limitations
The main strength of this study is the participation
of specialized rehabilitation institutions in different
countries, thus giving a broad impression of the topic
in different countries. Furthermore, the integration of
organizational and individual factors in understanding
how sexual health is understood and handled in spe-
cialized stroke rehabilitation units supplies a new and
important element to this research field. It should be no-
ted that these results are limited to the practice policies
adopted within individual stroke units at each hospital
and do not represent general administrative hospital
policies in general. A limitation when generalizing the
results may be the low response rate at some of the
centres, although the response rate overall is accept
able. There is a tendency of low response rate among
centres with high policy score and high response rate
among centres with lower scores, leaving a question as
to whether we have captured the most motivated staff
at high score centres. However, results from the study
indicate that information from hospital administration
on sexual health policies complies well with responses
from staff. The lowest response rate at 2 high-score
centres can be explained by organizational changes at
the time of survey (Sahlgrenska University Hospital,
Gothenburg) and political circumstances that limit the
possibility of staff to participate in the survey (Alamal
Rehabilitation Centre and Islamic University, Gaza).
Clinical implications
To the best of our knowledge this is the first study to
investigate sexual health policies at specialized stroke
rehabilitation centres and address the perspectives of
HCPs on sexual health in several countries in different
parts of the world. The present study supplies novel
knowledge on the importance of sexual health policy
and calls for action among stroke rehabilitation centres
to implement such policies.
Evidence-based practice in stroke rehabilitation is
needed and demanded, and clinical practice guidelines
and procedures on sexual health will need to be develo-
ped and implemented with increasing speed as research
evolves. Interventional studies are required on the effect
of implementing standard care sexual health procedures
on personnel taking action in addressing sexual health.
To overcome barriers preventing good clinical prac-
tice policies need to include defining roles and responsi-
J Rehabil Med 51, 2019