The association between pre-eclampsia and neonatal complications in relation to gestational age.

AIM: There has been limited research about the associations between pre-eclampsia and neonatal complications in relation to gestational age. This register-based study aimed to address that gap in our knowledge. METHODS: We used Swedish Medical Birth Register to carry out a population-based study on primiparas with singleton pregnancies from 1999 to 2017. Descriptive statistics and logistic regressions were used to study the associations between pre-eclampsia and neonatal complications in different gestational ages. The data is presented as adjusted odds ratios (aORs) with 95% CI. RESULTS: The study comprised 805 591 primiparas: 2.9% had mild to moderate pre-eclampsia and 1.4% had severe pre-eclampsia. Neonates born to women with pre-eclampsia had increased risks of several complications compared to those born to mothers without pre-eclampsia. After adjustment for confounding variables, the risk of being small for gestational age (aOR 5.3, CI: 5.1-5.5) and needing resuscitation (aOR 2.6, CI: 2.4-2.7) were increased. The risk of a low Apgar score and convulsions/hypoxic ischemic encephalopathy was increased at 32-41 weeks of gestation. Moreover, the overall risk of sepsis (aOR 1.9. CI: 1.8-2.1) and perinatal death (aOR 1.2, CI: 1.1-1.5) was also increased. CONCLUSION: Compared with infants of mothers without pre-eclampsia, those exposed to pre-eclampsia had higher risks of all the studied neonatal complications.

School children's perceptions about being offered the HPV vaccination - A focus group study.

AIM: There is limited knowledge about the perceptions of HPV vaccination in middle-school children. This qualitative study aimed to explore their views. METHODS: We conducted focus group interviews with children, 10-11 years of age, who had been offered HPV vaccination through the school health services in mid-north Sweden in spring of 2023. Data were analysed with qualitative content analysis. RESULTS: This study included six focus group interviews with 49 children (boys n = 29; girls n = 20), mean of 11 years of age. Participating children expressed the need to feel safe to be of utmost importance and the means to do so was to be prepared and informed by someone the child trusted. The school nurse was perceived as the expert, best suited to provide factual information, support and motivation, both to children and their parents. CONCLUSION: We confirm that healthcare providers' recommendations are crucial for HPV vaccine acceptance also from the child's perspective. Improved information about HPV vaccination to children is necessary. Children's right to participate on their own terms is not fulfilled today. Vaccine promotion, both to children and parents, should be actively managed by the school nurse.

To Feel Abandoned in an Insecure Situation: Parents' Experiences of Separation From Their Newborn Due to the Mother Being COVID-19 Positive.

BACKGROUND: The COVID-19 pandemic resulted in changes in neonatal care, sometimes resulting in a separation between parents and their newborn. Knowledge about parents' experiences of this separation is limited. PURPOSE: To explore parents' experiences of separation from their newborn due to COVID-19. METHODS: Interviews with parents (n = 11) separated from their newborn. RESULTS: The parents' experiences of being separated from their newborn were expressed under 3 themes: "To create a sense of safety in an insecure situation"; "Unexpected start to parenthood"; and "To be reunited." Parents felt abandoned and alone, even if they had support from significant others. Although they considered the separation as undesired, wanting to be with their newborn infant, it was secondary to not wanting to infect the infant with COVID-19. Furthermore, lacking information about a potentially lethal virus adds to the uncertainty that comes with having a newborn. The separation affected the whole family, some for a long time afterward. IMPLICATIONS FOR PRACTICE AND RESEARCH: If a new situation with potentially life-threatening effects, like the COVID-19 pandemic, occurs again, considering the experiences of these parents is paramount. Precautions should be taken to minimize the potential harm. If a separation between newborns and parents is inevitable, parents need preparation and transparent information prior to the separation and before the reunion. Well-thought-out policies must be in place to minimize the impact of a separation on both parties. Parents should be able to have a deputy parent present during an undesired but necessary separation from their newborn.

School Nurses' Perceptions and Experiences of Delivering a School-Based Intervention to Improve Primary Prevention of Human Papillomavirus Among Adolescents-A Focus Group Study Following a Randomized Controlled Trial.

The present qualitative study is a part of the process evaluation of a complex intervention, the randomized controlled trial, "Prevention of human papillomavirus (HPV) in a school-based setting." We aimed to explore participating school nurses' perceptions and experiences of delivering the educational HPV intervention to adolescents aged 16. Focus group interviews were conducted with school nurses (n = 20) and analyzed with inductive qualitative content analysis. The overall theme Easily adapted into the existing role as a school nurse permeated the participants' views. The nurses were in favor of delivering an intervention that increased the HPV vaccination rates and improved beliefs and awareness about HPV prevention. It suits their work and health-promoting aspect of their role well and can easily be adapted into the current school health consultant curriculum. Having material in different languages to share with adolescents and their parents to promote equal health was deemed important.

Users' Opinions of Internet-based Self-sampling Tests for Chlamydia trachomatis and Neisseria gonorrhoeae in Sweden.

Internet-based testing for Chlamydia trachomatis and Neisseria gonorrhoeae is a public health service in Sweden. However, knowledge about users of the service is limited. This study examined experiences of using the C. trachomatis/N. gonorrhoeae self-sampling service. Individuals ordering a free-of-charge C. trachomatis/N. gonorrhoeae self-sampling test from an eHealth website in 2018/2019 were invited to complete a questionnaire. Of the 1,785 participants 69.4% were women. The majority of participants (77.1%) were single and heterosexual (88.2%) and 5.3% of samples tested positive. The self-sampling service was appreciated, with > 90% considering it good/very good. The main reason subjects gave for testing was to check their health after unprotected sex (72.9%). Almost half (44.7%) had regretted having sex after alcohol intake. Differences in attitudes were seen between categories: born vs not born in Sweden, employed vs student, single vs married/having a partner. Participants were happy with the self-sampling test service, and sexual risk behaviours motivated use of the test.

Longer shared parental leave is associated with longer duration of breastfeeding: a cross-sectional study among Swedish mothers and their partners.

BACKGROUND: Breastfeeding is associated with health benefits for both the mother and infant and is therefore important to support; moreover, parental leave is a beneficial factor for breastfeeding. The Swedish parental leave is generous, allowing each parent to take 90 days; additionally, a further 300 days can be taken by either parent. Generally, mothers take 70% of the parental leave days, mainly during the first year. However, breastfeeding duration has declined in the last decade, and it is not known how shared parental leave is associated with the duration of breastfeeding. AIM: To investigate how parental leave is associated with the duration of exclusive and partial breastfeeding of the infant during the first 12 months after birth. An additional aim was to describe infants' and parents' characteristics and mode of birth in association with the duration of exclusive and partial breastfeeding. METHODS: This cross-sectional study was part of the Swedish Pregnancy Planning Study, conducted in Sweden in 2012-2015. The parents were recruited at 153 antenatal clinics in nine counties. In total, 813 couples completed a follow-up questionnaire 1 year after birth. Linear regression models were used to analyse the association between parental leave and the duration of breastfeeding. RESULTS: Infants were exclusively breastfed for, on average, 2.5 months (range 0-12 months) and partially breastfed, on average, 7 months (range 0-12 months). Most of the parental leave was taken by the mother (mean = 10.9 months) during the infant's first 12 months, while the partner took 3 months, on average. The parental leave (used and planned) during the infant's first 24 months were, on average, 21 months. In the multivariate linear regression analysis, mothers' and partners' high level of education (p < 0.001, p = 0.044, respectively), mothers' higher age (p = 0.049), non-instrumental vaginal birth (p = 0.004) and longer parental leave for the first 24 months (p < 0.001) were associated with longer duration of partial breastfeeding. CONCLUSION: The duration of partial breastfeeding was associated with higher parental educational level, higher age, non-instrumental vaginal birth and longer parental leave.

In everybody's interest but no one's assigned responsibility: midwives' thoughts and experiences of preventive work for men's sexual and reproductive health and rights within primary care.

BACKGROUND: Sexual and reproductive health and rights (SRHR) have historically been regarded as a woman's issue. It is likely that these gender norms also hinder health care providers from perceiving boys and men as health care recipients, especially within the area of SRHR. The aim of this study was to explore midwives' thoughts and experiences regarding preventive work for men's sexual and reproductive health and rights in the primary care setting. METHODS: An exploratory qualitative study. Five focus group interviews, including 4-5 participants in each group, were conducted with 22 midwives aged 31-64, who worked with reproductive, perinatal and sexual health within primary care. Data were analysed by latent content analysis. RESULTS: One overall theme emerged, in everybody's interest, but no one's assigned responsibility, and three sub-themes: (i) organisational aspects create obstacles, (ii) mixed views on the midwife's role and responsibility, and (iii) beliefs about men and women: same, but different. CONCLUSIONS: Midwives believed that preventive work for men's sexual and reproductive health and rights was in everybody's interest, but no one's assigned responsibility. To improve men's access to sexual and reproductive health care, actions are needed from the state, the health care system and health care providers.

Important but far away: adolescents' beliefs, awareness and experiences of fertility and preconception health.

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.

Immigrant women's experiences and views on the prevention of cervical cancer: a qualitative study.

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.

School nurses' attitudes and experiences regarding the human papillomavirus vaccination programme in Sweden: a population-based survey.

BACKGROUND: Sweden introduced a school-based human papillomavirus (HPV) vaccination programme in 2012, and school nurses are responsible for managing the vaccinations. The aim of the present study was to investigate the attitudes and experiences of school nurses regarding the school-based HPV vaccination programme 1 year after its implementation. METHODS: Data were collected using a web-based questionnaire in the spring of 2013, and 83.1% (851/1024) of nurses responded. RESULTS: There were strong associations between the nurses' education about the HPV vaccine and their perceived knowledge about the vaccine and a favourable attitude towards vaccination (both p < 0.001). School nurses who received a high level of education were more likely to have a positive attitude to HPV vaccination compared with nurses 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 with those with a low level of perceived knowledge (OR = 2.5; 95% CI: 1.299-4.955). If financial support from the government was used to fund an additional school nurse, nurses were more likely to have a positive attitude than if 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, mostly related to adverse effects. In addition, 570 (66.9%) stated that they had experienced difficulties with the vaccinations, 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 positive attitude 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.

Not the right time: why parents refuse to let their daughters have the human papillomavirus vaccination.

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 was 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.

Characteristics of good contraceptive counselling - An interview study.

OBJECTIVE: One key component in preventing unplanned pregnancies is to provide effective contraceptive counselling. This study aimed to investigate what characterises good contraceptive counselling from the woman's perspective. METHODS: A qualitative study with a phenomenological approach. Twenty-four women aged 15-45 participated in semi-structured, individual, face-to-face interviews that lasted, on average, one hour. Data were analysed by latent content analysis. RESULTS: One overall theme emerged, person-centred contraceptive counselling - an interactive process, with three main categories: (i) a trustworthy healthcare provider, (ii) creating a liaison and (iii) the right time and place. CONCLUSIONS: The healthcare provider's attributes as well as what happened between the healthcare provider and the woman, and the surrounding context, had a bearing on the women's descriptions of good contraceptive counselling. The process of the counselling was described as more important than the actual outcome; thus, healthcare providers need to be aware that this seemingly straightforward consultation is rather multi-layered and has great health promoting potential.

The association between early introduction of tiny tastings of solid foods and duration of breastfeeding.

BACKGROUND: Conflicting advice and non-evidence-based recommendations have a negative effect on breastfeeding. Since 2011, the National Food Agency in Sweden has informed parents that they can introduce tiny tastings (1 mL of solid food, i.e. other sources of nutrition than breastmilk/formula) to infants from four months of age. It is unknown how national recommendations, which differ from the Word Health Organisation's recommendation, affect breastfeeding. We hypothesised that introduction of tiny tastings of solid foods would shorten the duration of continued breastfeeding. METHODS: This retrospective study utilises data from the longitudinal 'Swedish Pregnancy Planning Study', in which mothers were recruited at antenatal clinics on a national level. The participants completed three questionnaires up to one year after birth (n = 1,251). Linear regression models were used to analyse the association between the introduction of solid foods and the duration of breastfeeding. RESULTS: As hypothesised, introduction of tiny tastings shortened the duration of continued breastfeeding. Half of all infants (48%) were fed with tiny tastings already in the fourth month. The correlation analysis showed that the earlier the infants started with tiny tastings, the earlier they ate larger amounts of solid food. In a multivariate linear regression analysis, five factors were identified as having a negative effect on the duration of breastfeeding: low infant age upon introduction of tiny tastings, low maternal age, low level of maternal education, high maternal BMI and twin birth. CONCLUSIONS: Early introduction of tiny tastings of solid foods shortened the duration of breastfeeding. It is difficult to influence most conditions that affect breastfeeding, for example, the mother's educational level, BMI, age and if she has given birth to twins. In contrast, national guidelines can always be updated. Recommendations from the Swedish authorities should adhere to the WHO's recommendation, which states exclusive breastfeeding for six months and continued breastfeeding for at least two years or longer.

Barriers in the School-Based Pan-Gender HPV Vaccination Program in Sweden: Healthcare Providers' Perspective.

BACKGROUND: Human papillomavirus (HPV) vaccines effectively prevent, and can even eliminate, HPV-related cancers. Currently, vaccination rates are suboptimal in the national Swedish school-based vaccination program. School nurses play a key role in all aspects of the vaccination process. Therefore, this study aims to explore school nurses' perceived HPV vaccination challenges. METHODS: Seven focus group interviews were conducted with school nurses (n = 35) working in nine socio-demographically diverse municipalities in mid-Sweden. Data were analyzed using qualitative content analysis. RESULTS: Participants described difficulties in encountering and handling the diversity of reasons for vaccine hesitancy. Parents known to be skeptical of vaccines in general were seen as most difficult to reach. Uncertainty was expressed concerning the extent of professional responsibility for vaccine promotion. The informants expressed a lack of guidelines for vaccine promotion and described challenges in supporting the child's own wishes. Creating a safe space for the individual child was seen as crucial. Other problems described were the challenges of overcoming children's fear of needles, supporting unvaccinated children, and being confronted with the remaining gender inequities of the pan-gender vaccination program. CONCLUSIONS: Our results suggest that school nurses, especially those new to their profession, may benefit from training and guidance22 material on how to address vaccine hesitancy.

Barriers towards HPV Vaccinations for Boys and Young Men: A Narrative Review.

BACKGROUND: HPV vaccination of both girls and boys can protect against infection and eliminate the risk for HPV-associated cancer. Due to a common misconception that the virus only poses risks to women, vaccine coverage is suboptimal among men in many countries. It is urgent to identify barriers to vaccination of boys and men. METHODS: We conducted a narrative review of publications examining attitudes and beliefs regarding HPV vaccination for boys and young men. The electronic databases searched were PubMed, PsychInfo and Scopus (December 2020; last update July 2021). A total of 103 original articles were included in the final analysis. RESULTS: The central barriers against vaccination of boys and men are: (1) lack of knowledge, (2) vaccine hesitancy in general, (3) lack of recommendation from and/or discussions with healthcare providers, (4) cost and logistics, and (5) the idea that HPV vaccination may promote promiscuity. Men who have sex with men and families belonging to ethnic minorities express a need for information tailored to their situation. CONCLUSIONS: Boys should be included in national immunization programs and men should also be offered catch-up vaccinations. Future studies should focus on addressing vaccine hesitancy and developing interventions to promote pan-gender HPV vaccination.

'To be on the safe side': a qualitative study regarding users' beliefs and experiences of internet-based self-sampling for Chlamydia trachomatis and Neisseria gonorrhoeae testing.

OBJECTIVES: In Sweden, an increasing number of tests for sexually transmitted infections are conducted. Self-sampling services are provided free of charge at the national eHealth website. Our aim was to obtain a deeper understanding of users' beliefs and experiences of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) self-sampling services. METHODS: This qualitative study is part of the national project 'Internet-based chlamydia and gonorrhoea self-sampling test', conducted in Sweden. Individuals ordering a CT/NG self-sampling test at home from the eHealth website were invited to participate. Of the 114 individuals who agreed, a purposeful sample including 20 women and men aged 18-49 years (mean, 30.8 years) participated in a telephone interview in 2019. RESULTS: The test service for CT/NG was highly appreciated by men and women of different ages. Round-the-clock accessibility, avoiding clinical visits, ease of use, confidentiality and a rapid test result were reasons for this appreciation. Language, uncertainty about the correct sampling procedure, unreliable postal services and concerns about handling of personal data were mentioned as barriers. Reasons for testing were checking after unprotected sex, symptoms, checking a partner's fidelity or a regular routine-'to be on the safe side'. Knowledge about the infections and their consequences was limited; some considered them severe, especially if they could threaten fertility, and others were less concerned. Disclosing an infection was described as emotionally stressful. Participants had high self-efficacy in relation to the test and would not hesitate to use the service again, even if it involved a cost. CONCLUSIONS: Internet-based CT/NG self-sampling at home was highly appreciated and was used for individual health reasons, but also out of concern for others' health and for society as a whole. The benefits seem to outweigh the barriers, and the service may therefore continue to be widely offered.

'I also want to be vaccinated!' - adolescent boys' awareness and thoughts, perceived benefits, information sources, and intention to be vaccinated against Human papillomavirus (HPV).

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.

Correction: Parents' knowledge, beliefs, and acceptance of the HPV vaccination in relation to their socio-demographics and religious beliefs: A cross-sectional study in Thailand.

[This corrects the article DOI: 10.1371/journal.pone.0193054.].

Parents' knowledge, beliefs, and acceptance of the HPV vaccination in relation to their socio-demographics and religious beliefs: A cross-sectional study in Thailand.

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.

Parents' views of including young boys in the Swedish national school-based HPV vaccination programme: a qualitative study.

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.