Background: Interventions delivered by mobile phone have been demonstrated to be effective in other health areas. This thesis focuses on interventions delivered by mobile phone to increase contraception use. Methods: This thesis comprises a systematic review, development and evaluation of the MObile Technology for Improved Family Planning (MOTIF) intervention to support postabortion contraception in Cambodia with randomised controlled trial, and a mixed methods process evaluation. Results: The systematic review identified five trials, two of which increased self-reported contraception use, one in the USA and the MOTIF trial in Cambodia (four-month data only). A meta-analysis was not possible due to differing interventions and outcome measures. Development of the MOTIF intervention involved literature reviews on determinants of contraceptive use, interviews and focus groups with women seeking abortion services in Cambodia. The intervention comprised six interactive voice messages with counsellor support depending on the response to the message. The intervention was associated with increased self-reported use of effective contraception at four months post-abortion (64% vs. 46%; Risk Ratio (RR): 1.39; 95% Confidence Interval (CI): 1.17–1.66) but not at 12 months (50% versus 43%; RR: 1.16; 95% CI: 0.92–1.47). Long-acting contraception use (intrauterine device, implant, permanent method) was increased at four and 12 months. There was no significant difference in repeat pregnancies or abortions at four or 12 months. The intervention effect was primarily due to increased initiation of long-acting contraception. The majority of women were positive about the intervention which provided support for physical and emotional issues in addition to contraception use. The intervention could be implemented in current form, however cost-effectiveness data is lacking. The intervention could potentially be improved and further evaluated. Conclusions: Interventions delivered by mobile phone can increase contraception use, but the evidence to date is mixed. Further trials of interventions delivered by mobile phone to increase contraception use are required.

This thesis tracks the process of how politics addresses the problem of youth sexual health by comparing policy texts from Sweden and England. The purpose is to seek new insights into how we are governed, following Foucault and his notion of ‘problematisation’. The analysis tracks the objectives and effects of power, revealing the kind of techniques, knowledges and mechanisms that make youth sexual health an intelligible and legitimate problem for policy. The research questions are: How is youth sexual health problematised in Swedish and English policy texts? And how do the English and Swedish problematisations of youth sexual health compare in terms of similarities and differences and how can these be understood? The analysis reveals a shared biopolitical problematisation in the Swedish and English texts, inspired by neoliberal aspirations of how to govern youth through freedom. Analytically, this can be described as a common governmentalised problem-space. However, the analysis also highlights the specificity of the effects of biopolitics, highlighting the contingent constellations of power emerging within each empirical context of youth sexual health, as biopolitics expands. Further, the frame of biopolitics proves particularly useful for comparative analysis as it bridges across empirical context revealing the systemic character of how biopower orders and administers the living, while also capturing local differences that allow meaningful theorisations on how youth sexual health is problematised in policy texts.

Background: This thesis examines the complex relationship between fertility intentions, contraception, and fertility in northern Malawi. Malawi has one of the highest contraceptive prevalence rates (CPR) in sub-Saharan Africa (42%), puzzlingly coupled with one of the highest fertility rates (5.7)[1]. Conventional assessments of contraception do not furnish a clear understanding of contraceptive dynamics. The Karonga Prevention Study (KPS) provides a unique opportunity to unpack these issues. Methods: A secondary data analysis was conducted to explore whether rates of conception varied by fertility intentions and contraceptive use in Karonga. A new one-year prospective longitudinal study collected provider-recorded data on contraceptive services, using patient-held records for 4,678 women aged 15-49, allowing an exploration of postpartum uptake, contraceptive switching and discontinuation. In-depth interviews explored women’s reasons for contraceptive choices and changes. Findings: Women who wanted a child within two years had a 45.5% chance of conceiving within two years, as compared to an 11.7% chance for women who wanted no more children. A novel construct of the CPR was used (the “actual CPR”) and estimated at 35.1%. There was high discontinuation of injectables and oral contraception pills (OCP) (only 51.2% of injection-users and 27.9% of OCP-users had their next injection/pill-cycle on time), and just 15.1% managed to adhere to the injection schedule consistently over 12 months. Amongst postpartum women, 28.4% initiated contraception within six months. Women viewed themselves as contraception users even if they were not using the methods consistently. Implications: The actual CPR was lower than conventional estimates, demonstrating that conventional estimates of contraceptive use must be corrected to account for periods of non-use. The reliance on short-term methods, and high discontinuation rates contribute to persistently high fertility in Malawi. In a context of relatively good provision of contraceptive services, quality of care must be improved, and strategies to motivate women to adhere to their method of choice must be employed. Promotion of long-acting methods is also key.

No description available.

Zimbabwe has experienced one of the largest HIV/AIDS epidemics. Heterosexual transmission accounts for the highest number of new infections. Current HIV prevention strategies rely heavily on changing individual behaviour to take up safer sex practices. However sexual activity is not just an individual attribute but behaviour negotiated between two people in a wider socio-cultural context particularly in marriage. There is thin literature on specific socio-cultural barriers that married women face when they negotiate for safer sex in marriage or context specific strategies to combat these barriers. This three phase study used qualitative data, collected through 4 focus group discussions, 36 semi-structured interviews with married men and women and 12 semi-structured interviews with HIV program implementers. Data were collected to examine the socio-cultural context of sexuality in marriage and identify interventions for empowering married women to negotiate for safer sex. The findings provide a contextually embedded analysis of the determinants of sex and sexuality in marriage and how these may shape powerlessness to negotiate for safer sex. Sexual satisfaction was perceived as a crucial aspect of sexuality in marriage with orgasm, sexual communication, sexual performance and frequency of sexual activity being crucial overlapping factors that contributed to it. Gender norms affected achieving sexual satisfaction in marriage, occurrence of forced sex and concurrent sexual relationships. Personal, social and cultural meanings of sex in a marriage along with ineffective communication and pressure from external social relationships were identified as barriers to safer sex uptake in marriage. Context specific interventions to address these barriers to safer sex practice in marriage were identified and assessed for socio-cultural and organisational feasibility. Future HIV interventions must go beyond narrowly advocating for safer sex strategies but address the complex socio-cultural determinants of sex in marriage.

This is a qualitative interpretive phenomenological study grounded in a feminist research ethic that draws on the narratives of fourteen young women, aged fifteen to eighteen. Semi-structured interviews were conducted to explore the young women's experiences of pregnancy, motherhood and education. The aim of this thesis is to examine how the young women believed becoming pregnant in their teenage years shaped and influenced their lives, with a particular focus on their education. The dichotomous constructions of teenage pregnancy in public, political and academic discourses as either highly problematic or as a positive and remarkable turning point are critically considered. Attention is paid to the value judgements that underlie these constructions of teenage pregnancy, problematising the kinds of agency that are positioned as appropriate for young women. The young women who participated in this research framed their pregnancy as an opportunity to change and improve their lives through education. They defined success through traditional definitions of citizenship and inclusion and viewed themselves as either socially included or socially excluded on the premise of whether they obtained paid employment. It is argued their narratives are shaped by feelings of stigma and shame and by recognition of their frequent positioning as 'problems' to be fixed. It is asserted that both constructions of teenage pregnancy as either 'negative' or as a 'positive' turning are invariably problematic as both overtly value and uncritically privilege education and employment. It is argued that both constructions position young women as projects to be worked on and to be transformed and improved, providing a limited and limiting definition of a successful and positive life.

Background: Improving the sexual health of young people is a key policy focus in Scotland. As the influence of the internet has grown within a rapidly changing health information landscape, so have opportunities for both sexual health promotion, and concerns about the challenges faced by young people in navigating this online environment. This study explores young people’s sexual health literacy (SHL), primarily within this online context. Methods: Paired interviews with friendship groups and observational online activities were used to explore young people’s experiences of finding, understanding and evaluating online sexual health information. A purposive sample of 49 participants (aged 16-19), diverse in terms of gender, sexuality and religion, were recruited from across Scotland from areas that varied in terms of deprivation and urban/rural classification. Findings: Participants varied in their confidence and ability to find and identify reliable information, and typically regarded identifying and filtering reliable sources as challenging. Barriers to accessing information on websites included: inaccessible language; inappropriate or non-relatable information; and websites that were difficult to navigate or did not function correctly. Concerns about stigma and ‘being seen’ seeking sexual health information was a key barrier. Stark differences, often mediated by gender, sexuality and educational circumstances, emerged in perspectives towards accessing sexual health information and support online. Findings suggest that different social media platforms present different opportunities and challenges; for example, social content sharing services such as YouTube may be useful venues for developing critical SHL, while social networking sites such as Facebook, may be less suitable to user’s active engagement in identity construction. Dissatisfaction with school-based sexual health education appears to be a catalyst for online information-seeking, but school-based sexual health education did little to equip young people to use the online environment effectively. Conclusions: Gender, sexual identity, stigma, structural factors and social support converge and intersect around young people’s SHL. A broad range of targeted interventions are needed to improve SHL, focusing on overcoming stigma, presenting positive messages and developing interactive and critical skills. Schools could do more to develop SHL skills, including teaching the digital and critical skills to seek and appraise online information. Expanding online sexual health services may effectively complement traditional services and encourage uptake, but it is essential that research establishes a robust, comprehensive conceptualisation of SHL, and develops measurement tools specific to SHL such that interventions can be evaluated and refined.

The aim of this study was to investigate the sexual health needs of undergraduate women aged 18-25 years old who were sexually active but not married or cohabiting; in order to put forward recommendations for a health promotion intervention which may be applied in the practice setting. The thesis consists of three linked qualitative studies. The Part 1 study was an in-depth exploration of the women’s sexual lifestyles and behaviours to identify their health promotion needs. This study was conducted using a phenomenological approach employing Interpretative Phenomenological Analysis (IPA). The Part 2 study was the systematic development of theoretically robust, evidence based intervention to respond to the health promotion needs identified in the Part 1 study. The third study was a consultation review of the initial materials with focus groups of undergraduate women aged 18-25 years old. The aim of which was to refine and amend the intervention to reflect the women’s perspectives. To undertake these tasks Intervention Mapping (IM) (Bartholomew et al., 2006) a health promotion programme planning framework was used as a guiding framework for the thesis. This study revealed the women traversed different types of sexual relationships. Within all types of relationships the women reported being risk averse and valued positive sexual health. Where a threat to sexual health was identified, they took action to reduce the threat. The threats identified differed depending on the relationship type. The distinct relationship types presented differing patterns of decision making, influenced by their values, emotional salience of the relationships and perception of sexual health risk. As such the different sexual health practices presented differing sexual health challenges and health promotion needs. This thesis suggests a quaternary model of female sexual agency outlining four distinct types of relationships - type (1) sexual debut and initial relationships, characterised by high emotion, type (2) casual sexual relationships, characterised by increasing sexual confidence and hedonistic attitudes, type (3) established but not permanent relationships, characterised by relationship stability but not sexual exclusivity (i.e. biological concurrency/behavioural concurrency) and type(4) marriage/cohabitation type relationships, characterised by increased sexual exclusivity. Many women described moving from type 1 relationships into type 2 relationships and then onto a type 3 relationship. However, once beyond type 1 the relationship types were not linear, the women described movement back and forth between type 2 and type 3 relationships. These were frequently with different partners, but could be with the same partner, for example; previous type 3 partners (established) could become a type 2 (casual partner). The study brought to light differing social constructs and expressions of female sexuality and sexual agency within the different relationship types. This enabled the identification of risk behaviours and their determinants, which in turn facilitated the process of intervention development. This enabled the creation of a tailored response to the women’s sexual health needs; thereby assisting the women to make fully informed contraceptive and sexual health choices. The study revealed how each step of the IM process contributes to the whole, augmenting the potential efficacy of the health promotion tools produced.

Female sterilisation or tubal ligation remains the most promoted and prevalent method of contraception in India today, especially among the rural and urban poor. This thesis provides an ethnographic account of poor women’s experiences of the sterilisation procedure in order to investigate the intricate relationship between the state, biomedicine and poor women in rural North India. The thesis draws on 18 months of ethnographic fieldwork in a mixed-caste village in Southern Rajasthan. Besides engaging with women in their daily lives in the village, participant observation was also carried out in regularly organised sterilisation camps, which were run by Marie Stopes India in two nearby towns. The thesis aims to explore how women experience the female sterilisation procedure, how this procedure relates to concerns beyond the sterilisation camp and how various forms and sources of authority influence reproductive decisions. The female sterilisation procedure encapsulates not only people’s engagements and negotiations with the power, practices and discourses of the state, but also with other forms of authority, such as biomedicine, and intersecting structures of gender, caste and class. The thesis approaches the main research theme – the relationship between the state, biomedicine and poor women in rural North India – by examining various relationships and power struggles within these domains as much as between them. The chapters focussing on the history of family planning in India, on local articulations of the state in the village and on local health workers who are an integral part of “motivating” women for the female sterilisation procedure reflect an effort to problematise “the state” and to investigate how local embodiments and discourses of the state contribute to women’s decisions to stop childbearing by undergoing the tubal ligation procedure. The ethnography of a sterilisation camp provides a look into processes of biomedical examinations conducted in the camp before the procedure, and shows how biomedical tools of knowing, seeing and acting are negotiated and contested by various biomedical personnel, bureaucrats, as well as by women seeking the procedure. In such a way, I problematise the category of “biomedicine” and highlight its contested nature. Finally, chapters on reproductive agency and operable bodies examine how women themselves make sense of tubal ligation, how they negotiate conditions under which to undergo the procedure, and how female sterilisation becomes a site to negotiate one’s social status. An ethnographic investigation of the state, biomedicine and poor women as categories which are not homogenous but rather are constituted through multiple internal and external contestations allows a deeper and more complex understanding of how increasing medicalisation of women’s lives in rural North India is experienced in various different ways. Furthermore, acknowledging the multiplicity of agendas, discourses and experiences within the categories of “the state”, “biomedicine” and “poor women” provides an insight into how power is contested and articulated on multiple levels and by multiple actors, resulting in theoretical contributions to the existing theories on power, governmentality and biopolitics.

To prevent unwanted pregnancies and sexually transmitted infections, sexually active individuals should practice safer sex (World Health Organisation 2008). This is important across the lifespan (Nusbaum and Rosenfeld 2004). But older and heterosexual populations are typically overlooked in safer sex interventions (Bodley-Tickell et al. 2008; Bowleg 2011). The Theory of Planned Behaviour (TPB) has been used to predict behaviour, and develop safer sex interventions (Fishbein and Ajzen 2010). But a criticism of the TPB is that it fails to recognise the emotional aspect of safer sex (Norton et al., 2005). Extending the TPB to include affective attitudes has enhanced the effectiveness of safer sex interventions (Ferrer et al. 2011). Furthermore, safer sex typically involves a series of five condom-related behaviours; accessing, carrying, negotiating, using and disposing (Moore et al. 2006). Yet most interventions promote only one condom-related behaviour. In addition, the internet is now being used more as a platform for delivering interventions (Kraft and Yardley 2009). For safer sex interventions, online delivery may help reduce the embarrassment individuals often report when discussing sexual health (Qulliam 2011). Therefore, the aim of this thesis was to develop and evaluate an online safer sex intervention to promote performance of multiple condom-related behaviours in a broad population. A series of studies were conducted in order to develop the intervention. Study 1, an online elicitation study with 26 individuals, used an extended TPB framework to explore attitudinal, normative and control beliefs toward performing five condom-related behaviours. Findings suggested that individuals hold a range of attitudinal, normative and control beliefs toward performing these condom-related behaviours. Study 2, an online questionnaire study with 363 individuals identified beliefs and behaviours for intervention target. Findings suggested that three condom-related behaviours should be promoted; carrying, negotiating and using. In addition, analysis showed that affective and moral norm beliefs were most predictive of intention to perform these three condom-related behaviours, and should be the intervention targets. Study 3 was an online intervention with 439 individuals. Individuals were randomised to one of three conditions; control message, positively- or negatively-framed persuasive message. TPB and self-report behaviour measures were taken pre-, immediately post-intervention and three months later. Findings demonstrated that performance of condom-related behaviours did not significantly increase from participation in the intervention. However, intention to carry and use condoms increased over time regardless of intervention condition in all populations sampled. Overall, findings from this thesis support the development of safer sex interventions that promote multiple condom-related behaviours in a broad population. However, findings suggested that persuasive messages targeting psychological constructs of the TPB do not change intentions better than a control message in a broad population. From a public health perspective, these findings suggest that highlighting the benefits of performing condom-related behaviours may be sufficient to strengthen intentions. These strengthened intentions may be protective in the future if the situation arises for an individual which requires the performance of these behaviours. Recommendations for future safer sex research are considered.