The study has two separate but related aims, which are to explore the social and health experiences of men who are in polygynous relationships and to develop holistic health and social strategies to support men who are in polygynous relationships. Objectives of the study were to identify the different permutations of polygynous relationships that related to health and social issues; to clarify the social status of men who are in polygynous relationship; to explore and describe the health experiences of men in polygynous relationship; to explore and describe the social experiences of men in polygynous relationship; to explore the spiritual experiences of men who are in a polygynous relationship; to describe and to generate holistic strategies to support men who are in a polygynous relationships. Method: In this study, the researcher used descriptive and interpretive phenomenological processes to develop a range of holistic strategies to support men who were in polygynous relationships. The researcher described the experiences and developed interpretations based on the lived experiences that the men reported. Findings: Polygyny remains the reality within the Bapedi tribe in Sekhukhune area. The practice of polygyny is not only for the affluent as indicated in most literature but is also practiced as a corrective strategy for families who are experiencing marital problems. Polygyny is not viewed as abusive to the women and children but rather beneficial to the women. It helps to reduce the risks of the development of cervical cancer that is predisposed by frequency of sexual intercourse. Polygyny promotes the morals within the communities, as children grow up within the two parents’ environment as opposed to the rising numbers of single parent families. Polygyny practice in the Sekhukhune areas is a voluntary choice and not a forced marital arrangement. Conclusions and recommendations: The researcher recommended policy guidance to support health practitioners with strategies to assist members of polygynous families in need of help. The policy also guides employers to recognise and to register the second or third wife as beneficiaries of the working husband. / Health Studies / D. Litt. et Phil . (Health Studies)

This quantitative, explorative and descriptive survey attempted to determine factors that influence the adolescent pregnancy rate in the Greater Giyani Municipality. Data were gathered from adolescent girls attending four selected high schools. Non-probability convenient sample of 147 respondents was used with 100% return rate. Data was collected using a questionnaire which had a reliability of 0.65. Data were analysed using the SAS/Basic computer program, version 9.2. Findings indicated that 56.34% of respondents reported key psychosocial variables such as peer pressure and 58.90% of them changed values as contributory to high pregnancy rates. .Health services were reported as not freely available and relationships with nurses significantly cited as poor by 72.41% respondents with regard to maintenance of confidentiality. Recommendations were made to improve school health services, reproductive education and future research / Health Studies / M.A. (Health Studies)

This study was intended to explore the role male partners play in preventing adolescent pregnancy in the Letlhabile area, of Brits district, which is located in the North West Province. Adolescent males and females whose ages ranged between 13-20 years were included in the sample. The inclusion criteria was determined on the basis of the adolescents who were pregnant and non- pregnant, as well as males who had already became parents and those who hadn't experienced fatherhood. Focus group discussions and individual in-depth interviews were conducted.ObservaJions and the review of existing documents were triangulated to gather valid and reliable information. Quantitative and qualitative data analysis were blended. The findings revealed significant factors that ranged from the reaction of parents and/or partner to the announcement of pregnancy, to issues that impact on consequences of multiple sex partners. The recommendations of this project deal with aspects that include contraception, sexuality education, parental involvement among many relevant policy issues. / Health Studies / M.A. (Nursing Science)

The purpose of this study was to assess men’s knowledge and attitude towards vasectomy as a family planning method options available to men in East Wollega zone of Oromia Region. Male sterilisation in sub-Saharan countries including Ethiopia is very much limited due to lots of reasons despite its many advantages than other family planning methods. Quantitative, descriptive cross-sectional research was used to describe level of knowledge and attitude towards vasectomy. Data were collected using structured questionnaire in which a total of 150 respondents, who were selected using non-random purposive sampling technique participated in the study. The data were analysed using SPSS version 20. Hence the findings revealed the lack of knowledge and low interest on vasectomy among respondents. The concerted effort from all stakeholders and use of multiple strategies to educate the community will raise awareness which in turn improves vasectomy service uptake / Health Studies / M.A. (Public Health)

BACKGROUND: Studies done in both developed and developing countries have reported the tendencies of adolescents to engage in risky behaviours. Such behaviours include indulging in early and unsafe sexual activities, having multiple sexual partners, alcohol and drug use and dropping out of school among others. PURPOSE: The main aim of the study was to develop intervention strategies for reducing sexual risk practices among adolescents in Ethiopia. METHODS: A mixed method approach using quantitative and qualitative approaches was employed in order to investigate the risks of sexual practices among urban and rural adolescents in the selected area. A cross-sectional survey was used to gather data quantitatively and focus group discussions were used for the qualitative part of data collection. A total of 449 students and 72 FGD participants were selected for quantitative and qualitative study respectively using systematic random sampling technique. Logistic regression was done to identify possible factors associated with knowledge on emergency contraceptive, condom utilisation, pre-marital sex practices and perception of risky sexual practices. RESULTS: One hundred and seventy (37.9%) respondents had experienced sexual intercourse at the time of the study. The higher proportion (42.6%) of those who had engaged in sexual relationships was from the rural school compared to 33.1% in the urban schools. The proportion of sexually active respondents was higher among males (44.8%) compared to (29%) females. Multiple partners were higher in rural adolescents (44.7%) compared to 31.8% among urban adolescents. Sexually Transmitted Diseases were reported by 28.6% of the sexually active adolescents and the prevalence was higher among males (73.5%) compared to 27% females. 87% of the sexually active adolescents rarely used a condom. CONCLUSION: The study identified a knowledge gap on ASRH which limited adolescents to access reproductive services. Social, cultural and economic factors contributed to adolescent engagement in risky sexual behaviours. Based on the major findings of this study, intervention strategies targeting behavioural, biomedical and structural interventions were proposed. / Health Studies / D. Litt. et Phil. (Health Studies)

This dissertation fundamentally explores the nature of change, and the development interventions that aim to bring this change into a particular society. What emerges is the notion of a ‘spiral’: imagining the dynamic relationship between paradigms and discourses, the institutions and programmes operating in a place, and the way individual identities are constructed in intricate and contradictory ways. Within this spiral, discourse has power – ‘words matter’ – but equally significant is how these words interact dialogically with concrete social structures and institutions – ‘it takes more than changing words to change the world’. Furthermore, these changes are reacted to, and expressed in, the physical, sexed body. In essence, change is ideational, institutional, and embodied. To investigate the politics of change, this dissertation analyses the spiral relationships between gender discourses, institutions, and identities in contemporary Indonesia, focusing on their transmission across Java. It does so by exploring the Indonesian state’s gender policies in the context of globalisation, democratisation, and decentralisation. In this way, the lens of gender allows us to analyse the dynamic interactions between state and society, between ideas and institutions, which impact on everything from cultural structures to physical bodies. Research focuses on the gender policies of the Indonesian Ministry of Women’s Empowerment, substantiated with case study material from United Nations Population Fund reproductive health programmes in West Java. Employing a multi-level, multi-vocal theoretical framework, the thesis analyses gender discourses and relational structures (how discourses circulate to construct the Indonesian woman), gender institutions and social structures (how discourses are translated into programmes), and gender identities and embodied structures (how discourses enter the home and the body). Critically, studying gender requires analysing the human body as the site of both structural and symbolic power. This dissertation thus argues for renewed emphasis on a ‘politics of the body’, recognising that bodies are the material foundations from which gender discourses derive their naturalising power and hence ability to structure social relations. The danger of forgetting this politics of the body is that it allows for slippage between ‘gender’ and ‘women’; policy objectives cannot be disentangled from the reality of physical bodies and their social construction. This thesis therefore argues that there are distinct and even inverse impacts of gender policies in Indonesia. As the ‘liberal’ and ‘modern’ assumptions of gender equality are overlaid onto the patriarchal culture of a society undergoing transformation, women’s bodies and women’s sexuality are always and ever the focus of the social gaze. The gender policies and interventions affecting change on discursive and institutional levels may thus provoke reaction at the level of individual identities that are contrary to explicit intentions. In effect, projects that purport to work on ‘gender’ are often so deeply rooted in underlying gender normativity that their net effect is to reinscribe these gender hierarchies. By exposing the contradictions in these underlying paradigms we gain insight into the politics of a transforming society. Furthermore, engaging with the politics of the body allows us to analyse the spiral processes between discourse and practice, the question of power, and the way men and women embody social structures and experience social transformation.

Problématique : Depuis bientôt deux décennies, la République Démocratique du Congo (RDC) est le territoire d’un conflit armé qui, selon l’International Rescue Commite, aurait occasionné plus de 3 millions de décès et autant de déplacés internes. Plusieurs rapports font également cas des nombreux actes de violence sexuelle (les viols, les mutilations, l’esclavage, l’exploitation sexuelle, etc.) commis envers les filles, les femmes et dans une moindre ampleur les hommes. S’il existe un consensus sur le côté barbare des actes de violence sexuelle liés aux conflits armés, rares sont les études qui ont évalué leurs conséquences sur la santé reproductive des survivantes surtout en termes d’issues telles que les fistules, les douleurs pelviennes chroniques (DPC), le désir de rapports sexuels, le désir d’enfant et le désir d’interruption de la grossesse issue de tels actes. Par ailleurs, même si la santé mentale des populations en zones de conflit représente un sujet d’intérêt, l’impact spécifique de la violence sexuelle liée au conflit sur la santé mentale des survivantes a été peu étudié. De plus, ces travaux s’intéressent aux effets de la violence sexuelle liée au conflit sur la santé mentale et sur la santé reproductive séparément et ce, sans évaluer les relations qui peuvent exister entre ces deux dimensions qui, pourtant, s’influencent mutuellement. Aussi, l’impact social de la violence sexuelle liée au conflit, ainsi que la contribution des normes socioculturelles aux difficultés que rencontrent les survivantes, a été peu étudié. Pourtant, l’impact social de la violence sexuelle liée au conflit peut permettre de mieux comprendre comment l’expérience d’un tel acte peut affecter la santé mentale. Enfin, aucune étude n’a évalué les effets de la violence sexuelle liée au conflit en la comparant à la violence sexuelle non liée au conflit (VSNLC). Pourtant, il est reconnu qu’à de nombreux égards, la violence sexuelle liée au conflit est bien différente de la VSNLC puisqu’elle est perpétrée avec l’intention de créer le maximum d’effets adverses pour la victime et sa communauté. Objectifs : Les objectifs poursuivis dans cette thèse visent à : 1) évaluer les effets de la violence sexuelle liée au conflit sur la santé reproductive; 2) évaluer les effets de la violence sexuelle liée au conflit sur la santé mentale en termes de sévérité des symptômes de stress posttraumatique (PTSD), de sévérité des symptômes de détresse psychologique et de probabilité de souffrir de troubles mentaux communs (TMC); 3) évaluer la contribution des troubles physiques de santé reproductive, en particulier les fistules et les douleurs pelviennes chroniques (DPC), aux effets de la violence sexuelle liée au conflit sur la santé mentale; 4) évaluer la contribution de l’état de santé mentale aux effets de la violence sexuelle liée au conflit sur le désir de rapports sexuels et le désir d’enfant; et 5) étudier l’impact de la violence sexuelle liée au conflit sur le plan social ainsi que la contribution des normes socioculturelles à ses effets adverses et la façon dont ces effets pourraient à leur tour influencer la santé des femmes et leur relation avec l’enfant issu de l’acte de violence sexuelle subi. Méthodologie : Un devis mixte de nature convergente a permis de collecter des données quantitatives auprès de l’ensemble des participantes (étude transversale) et des données qualitatives sur un nombre plus restreint de femmes (étude phénoménologique). Une étude transversale populationnelle a été conduite entre juillet et août 2012 auprès de 320 femmes âgées de 15 à 45 ans habitant quatre (4) quartiers de la ville de Goma située dans la province du Nord-Kivu en RDC. Les femmes ont été recrutées à travers des annonces faites par les responsables des programmes d’alphabétisation et de résolution de conflits implantés dans les différents quartiers par le Collectif Alpha Ujuvi, une ONG locale. Les issues de santé reproductive évaluées sont : les fistules, les DPC, le désir de rapports sexuels, le désir d’enfant et le désir d’interruption de la grossesse issue d’un acte de violence sexuelle. Les variables de santé mentale d’intérêt sont : la sévérité des symptômes de détresse psychologique, la sévérité des symptômes de PTSD et la probabilité de souffrir de TMC. Pour les analyses, l’exposition a été définie en trois (3) catégories selon l’expérience passée de violence sexuelle : les femmes qui ont vécu des actes de violence sexuelle liée au conflit, celles qui ont vécu des actes de VSNLC et celles qui ont déclaré n’avoir jamais subi d’acte de violence sexuelle au cours de leur vie. Les variables de confusion potentielles mesurées sont : l’âge, le statut matrimonial, le nombre d’enfants, le niveau d’éducation le plus élevé atteint et l’occupation professionnelle. Les mesures d’associations ont été évaluées à l’aide de modèles de régressions logistiques et linéaires simples et multiples. Des tests d’interaction multiplicative et des analyses stratifiées ont été également conduits pour évaluer l’effet potentiellement modificateur de quelques variables (âge, statut matrimonial, nombre d’enfants) sur la relation entre la violence sexuelle et les variables de santé reproductive ou de santé mentale. Ces tests ont également été utilisés pour évaluer la contribution d’une variable de santé reproductive ou de santé mentale aux effets de la violence sexuelle sur l’autre dimension de la santé d’intérêt dans cette étude. Une étude phénoménologique a été conduite dans le même intervalle de temps auprès de 12 femmes ayant participé à la partie quantitative de l’étude qui ont vécu la violence sexuelle liée au conflit et ont eu un enfant issu d’une agression sexuelle. Les sujets explorés incluent : la perception de l’acte de violence sexuelle liée au conflit vécu et de la vie quotidienne par les victimes; la perception de l’acte de violence sexuelle liée au conflit par la famille et l’entourage et leurs réactions après l’agression; la perception de la grossesse issue de l’acte de violence sexuelle par la victime; la perception de l’enfant issu de la violence sexuelle liée au conflit par la victime ainsi que son entourage; les conséquences sociales de l’expérience de violence sexuelle liée au conflit et les besoins des victimes pour leur réhabilitation. Une analyse thématique avec un codage ouvert a permis de ressortir les thèmes clés des récits des participantes. Par la suite, l’approche de théorisation ancrée a été utilisée pour induire un cadre décrivant l’impact social de l’expérience de la violence sexuelle liée au conflit et les facteurs y contribuant. Résultats : Le premier article de cette thèse montre que, comparées aux femmes qui n’ont jamais vécu un acte de violence sexuelle, celles qui ont vécu la violence sexuelle liée au conflit ont une probabilité plus élevée d’avoir une fistule (OR=11.1, IC 95% [3.1-39.3]), des DPC (OR=5.1, IC 95% [2.4-10.9]), de rapporter une absence de désir de rapports sexuels (OR=3.5, IC 95% [1.7-6.9]) et une absence de désir d’enfant (OR=3.5, IC 95% [1.6-7.8]). Comparées aux mêmes femmes, celles qui ont vécu la VSNLC ont plus de probabilité de souffrir de DPC (OR=2.3, IC 95% [0.95-5.8]) et de rapporter une absence de désir d’enfant (OR=2.7, IC 95% [1.1-6.5]). Comparées aux femmes qui ont vécu la VSNLC, celles qui ont vécu la violence sexuelle liée au conflit ont également une probabilité plus élevée d’avoir une fistule (OR=9.5, IC 95% [1.6-56.4]), des DPC (OR=2.2, IC 95% [0.8-5.7]) et de rapporter une absence de désir de rapports sexuels (OR=2.5, IC 95% [1.1-6.1]). En ce qui concerne les grossesses issues des viols, comparées aux femmes qui ont vécu la VSNLC, celles qui ont vécu la violence sexuelle liée au conflit sont plus nombreuses à souhaiter avorter (55% vs 25% pour celles qui ont vécu la VSNLC). Elles sont également plus nombreuses à déclarer qu’elles auraient avorté si les soins appropriés étaient accessibles (39% vs 21% pour celles qui ont vécu la VSNLC). Le second article montre qu’en comparaison aux femmes qui n’ont jamais subi de violence sexuelle, celles qui ont vécu la violence sexuelle liée au conflit présentent des symptômes de détresse psychologique (moyennes de score respectives 8.6 et 12.6, p<0.0001) et des symptômes de PTSD (moyennes de score respectives 2.2 et 2.6, p<0.0001) plus sévères et ont plus de probabilité d’être dépistées comme un cas de TMC (30% vs 76%, p<0.0001). De plus, comparées aux femmes qui ont vécu la VSNLC, celles qui ont vécu la violence sexuelle liée au conflit présentent des symptômes de détresse psychologique (moyennes de score respectives 10.1 et 12.6, p<0.0001) et des symptômes de PTSD (moyennes de score respectives 2.2 et 2.6, p<0.0001) plus sévères et ont plus de probabilité d’être dépistées comme un cas de TMC (48% vs 76%, p<0.001). Les valeurs minimales et maximales de score de sévérité de symptômes de détresse psychologique sont de 0/12 pour les femmes qui n’ont jamais vécu de violence sexuelle, 4/19 pour celles qui ont vécu la VSNLC et de 5/18 pour celles qui ont vécu la violence sexuelle liée au confit. En ce qui concerne la sévérité des symptômes de PTSD, les scores minimal et maximal sont respectivement de 0.36/3.22, 0.41/3.41 et 0.95/3.45. Le fait d’avoir développé une fistule ou de souffrir de DPC après l’agression sexuelle augmente la force des associations entre la violence sexuelle et la santé mentale. Les femmes qui ont subi la violence sexuelle liée au conflit et qui ont souffert de fistules présentent des symptômes de détresse psychologique et de PTSD plus sévères comparées aux femmes qui ont subi la violence sexuelle liée au conflit mais n’ont pas de fistules. Les résultats sont similaires pour les femmes qui ont subi la violence sexuelle liée au conflit et qui souffrent de DPC. Des résultats complémentaires suggèrent que le statut matrimonial modifie l’effet de la violence sexuelle sur la sévérité des symptômes de détresse psychologique, les femmes divorcées/séparées et les veuves étant celles qui ont les moyennes de score les plus élevées (respectivement 11.3 et 12.1 vs 9.26 et 9.49 pour les célibataires et les mariées). Par ailleurs, la sévérité des symptômes de détresse psychologique modifie l’association entre la violence sexuelle liée au conflit et le désir d’enfant. Le troisième article montre que, sur le plan social, l’expérience de violence sexuelle liée au conflit entraine également de lourdes conséquences. Toutes celles qui ont vécu ce type d’acte décrivent leur vie de survivante et de mère d’un enfant issu d’une agression sexuelle comme difficile, oppressive, faite de peines et de soucis et sans valeur. Plusieurs facteurs influencent la description que les victimes de violence sexuelle liée au conflit font de leur vie quotidienne, et ils sont tous reliés aux normes socioculturelles qui font de la femme une citoyenne de seconde zone, ne font aucune différence entre un viol et un adultère, condamnent les victimes de violence sexuelle plutôt que leurs agresseurs, rejettent et stigmatisent les victimes de tels actes ainsi que l’enfant qui en est issu. En réponse au rejet et au manque de considération, les femmes victimes de violence sexuelle liée au conflit ont tendance à s’isoler pour éviter les insultes et à garder le silence sur leur agression. En plus, les réactions de leur entourage/communauté ont tendance à leur faire revivre l’agression sexuelle subie, autant d’éléments qui nuisent davantage à leur réhabilitation. D’autres résultats démontrent que les enfants issus d’actes de violence sexuelle liée au conflit sont également rejetés par leur communauté, leur famille adoptive ainsi que le conjoint de leur mère, ce qui affecte davantage les survivantes. Avec leurs mères, les relations développées varient entre le rejet, la résignation et l’affection. Néanmoins, ces relations sont plus souvent tendues probablement à cause de la stigmatisation de la communauté. Conclusion: La violence sexuelle liée au conflit a des effets adverses sur la santé reproductive, la santé mentale mais également sur le plan social. Ces trois dimensions sont loin d’être isolées puisque cette étude a permis de démontrer qu’elles s’influencent mutuellement. Ceci suggère que la prise en charge des victimes de violence sexuelle liée au conflit ne doit pas se concentrer sur un aspect ou un autre de la santé mais prendre en compte l’ensemble des dimensions de la femme pour offrir une aide holistique, plus adaptée et qui sera plus efficace à long terme. / Background: Since nearly two decades, the Democratic Republic of Congo (DRC) is ravaged by an armed conflict which, according to the International Rescue Commitee, have caused more than 3 million deaths and as many internally displaced persons. Several reports also denounce the numerous cases of sexual violence (rape, mutilation, sexual slavery, exploitation, etc.) committed against girls, women, and to a lesser extent against men. Even if there is a consensus on the barbaric nature of conflict-related sexual violence acts, few studies have assessed its effects on survivors’ reproductive health especially in terms of issues such as fistulas, chronic pelvic pain (CPP), desire for sex, desire for children, and desire to interrupt pregnancy resulting from rape. Moreover, even if the mental health of populations in conflict zones is a topic of interest, the specific impact of conflict-related sexual violence on the survivors’ mental health has not been much studied. In addition, most studies research the effects of conflict-related sexual violence on mental health and on reproductive health separately without assessing the relationships that can exist between these two dimensions which, however, influence each other. Also, the social impact of conflict-related sexual violence, and the contribution of sociocultural norms to the survivors’ struggles, has not been much studied. Nevertheless, the social impact of conflict-related sexual violence may help in understanding how the experience of such act can affect mental health. Finally, no study has investigated the effects of conflict-related sexual violence by comparing it to non-conflict- related sexual violence (NCRSV). However, it is recognized that, in many respects, conflict- related sexual violence is very different from NCRSV since it is committed with the intent to create the most adverse effects on the victims and their community. Objectives: The objectives of this thesis aimed at: 1) assessing the effects of conflict- related sexual violence on reproductive health; 2) evaluating the effects of conflict-related sexual violence on mental health in terms of severity of posttraumatic stress disorder (PTSD) symptoms, severity of psychological distress symptoms, and the likelihood of suffering from common mental disorders (CMD); 3) assessing the contribution of adverse reproductive health issues, particularly fistula and chronic pelvic pain (CPP) to the effect of conflict-related sexual violence on mental health; 4) assessing the contribution of mental health state to the effect of conflict-related sexual violence on desire for sexual intercourse, and desire for children; and 4) studying the social impact of conflict-related sexual violence as well as the contribution of sociocultural norms to its adverse consequences, and how these effects could in return affect women’s health and their relationship with their rape-conceived children. Methodology: A convergent mixed design allowed collection of quantitative data from all participants (cross-sectional study) and qualitative data on a smaller number of women (phenomenological study). A population-based cross-sectional study was conducted between July and August 2012 among 320 women, aged 15 to 45, living in four (4) neighbourhoods of the city of Goma, province of North Kivu in the DRC. Participants were recruited through announcements made by those responsible for literacy and conflict-resolution programs implemented in different neighbourhoods by the Collectif Alpha Ujuvi, a local NGO2. Reproductive health outcomes assessed are: fistulas, CPP, desire for sex, desire for children and desire to interrupt pregnancy resulting from sexual violence. The mental health outcomes of interest were: severity of psychological distress symptoms, severity of PTSD symptoms, and likelihood of suffering from CMD. For analyses, exposure was defined in three (3) categories according to past experience of sexual violence: women who experienced conflict-related sexual violence, those who experienced NCRSV, and those who reported never having been victim of sexual violence in their lifetime. Potential confounders assessed were: age, marital status, number of children, highest education level reached, and occupation. Measures of association were assessed using simple and multiple logistic and linear regression models. Multiplicative interaction tests and stratified analyzes were also conducted to identify the potential modification effect of the variables age, marital status and number of children on the association between sexual violence and reproductive health or mental health. Those tests were also used to assess the contribution of reproductive health or mental health to the effects of sexual violence on the other aspect of health of interest in this study. In the meantime, a phenomenological study was conducted among 12 women who experienced conflict-related sexual violence, had a rape-conceived child, and participated in the quantitative part of the study. Topics explored include: perception of the act of conflict- related sexual violence and the daily life by the victims; perception of the act of rape by the victims’ family and entourage and their reaction after the aggression; perception of pregnancy resulting from sexual violence by the victim; perception of the rape-conceived child by the victim and her entourage; social consequences of experiencing conflict-related sexual violence, and victims' needs for rehabilitation. A thematic analysis with open coding has highlighted the key themes of the participants’ stories. Thereafter, a grounded theory approach was used to induce a framework outlining the social impact of experiencing conflict-related sexual violence along with the contributing factors. Results: The first article of this thesis shows that, compared to women who have never experienced sexual violence, women who experienced conflict-related sexual violence have a higher probability to have fistula (OR=11.1, 95% CI [3.1-39.3]), CPP (OR=5.1, 95% CI [2.4- 10.9]), an absence of desire for sexual intercourse (OR=3.5, 95% CI [1.7-6.9]), and an absence of desire for children (OR=3.5, 95% CI [1.6-7.8]). Compared with the same women, those who have experienced NCRSV are more likely to have CPP (OR=2.3, 95% CI [0.95-5.8]), and an absence of desire for children (OR=2.7, 95% CI [1.1-6.5]). Compared with women who have experienced NCRSV, those who experienced conflict-related sexual violence also have higher odds for fistula (OR=9.5, 95% CI [1.6-56.4]), CPP (OR=2.2, 95% CI [0.8-5.7]), and absence of desire for sexual intercourse (OR=2.5, 95% CI [1.1-6.1]). Regarding pregnancy resulting from sexual violence, in comparison to women who experienced NCRSV, a higher proportion of those who experienced conflict-related sexual violence were willing to abort (55% vs. 25% for those who experienced NCRSV). They are also more likely to admit that they would have done so, if proper care was available (39% vs. 21% for those who experienced NCRSV). The second article shows that, compared to women who have never experienced sexual violence, those who experienced conflict-related sexual violence have more severe symptoms of psychological distress (respective score means 8.6 and 12.6, p<0.0001) and PTSD (respective score means 2.2 and 2.6, p<0.0001), and are more likely to be probable CMD case (30% vs. 76%, p<0.0001). Moreover, compared to women who experienced NCRSV, those who experienced conflict-related sexual violence have more severe symptoms of psychological distress (respective score means 10.1 and 12.6, p<0.0001) and PTSD (respective score means 2.2 and 2.6, p<0.0001), and are more likely to be probable CMD case (48% vs. 76%, p<0.0001). The lowest and highest scores of severity of psychological distress symptoms are 0/12 in the category of women who never experienced sexual violence, 4/19 in the category of women who experienced NCRSV and 5/18 in the category of women who experienced conflict-related sexual violence. Regarding the severity of PTSD’s symptoms, the lowest and highest scores are respectively: 0.36/3.22, 0.41/3.41 and 0.95/3.45. Suffering from fistula or CPP increases the strength of the association between sexual violence and mental health. Women who experienced conflict-related sexual violence and suffered fistula, compared to those who experienced conflict-related sexual violence and did not suffer from fistula, have more severe symptoms of psychological distress and PTSD. Results were similar for women who experienced conflict-related sexual violence and have CPP. Complementary results suggest that the marital status modifies the association between sexual violence and severity of psychological distress symptoms, divorced/separated and widowed being those who have the highest score means (respectively 11.3 and 12.1 vs. 9.26 and 9.49 for singles and married women). Furthermore, the severity of psychological distress symptoms changes the association between conflict-related sexual violence and desire for children. The third article shows that, on the social front, experiencing conflict-related sexual violence also results in serious consequences. All women who experienced this type of act describe their life of survivor and mother of a child born from rape as difficult, oppressive, made of worries and sorrows, and worthless. Several factors influence the description that victims of conflict-related sexual violence make of their daily lives, and they are all related to socio-cultural norms which consider women as second class citizen, do not make any difference between rape and adultery, condemn rape victims rather than the perpetrators, reject and stigmatize raped women and rape-conceived children. In response to the rejection and lack of consideration, survivors of conflict-related sexual violence tend to isolate themselves to avoid insults, and keep quiet about the aggression they suffered. In addition, the reactions of their entourage/community tend to revive memories of the aggression they suffered, all of which may impair their rehabilitation. Other results show that children resulting from conflict-related sexual violence are also rejected by their communities, as well their adoptive family and their mother’s partner and this hurts the victims. With their mothers, relationships developed range from rejection, resignation to affection. Nevertheless, these relationships are often more likely to be strained because of the stigma of the community. Conclusion: Conflict-related sexual violence has adverse effects on reproductive health and mental health. It is also associated with adverse social consequences. Those three dimensions are far from being isolated because this study demonstrated that they do influence each other. This suggests that intervention programs for victims of conflict-related sexual violence should not only focus on one aspect of health but take into account all the dimensions of a woman to provide holistic and more appropriate support which will be more effective in the long term.

O conceito de saúde sexual e reprodutiva (SSR) ganha visibilidade na década de 1990, marcada por ativismo social e pela IV Conferência Internacional sobre População e Desenvolvimento e a IV Conferência Internacional sobre Mulheres, que afirmam a atenção primária à saúde (APS) como prioritária. No Brasil, a APS é considerada estratégica para efetivar políticas de SSR no Sistema Único de Saúde (SUS). Com o objetivo de avaliar a implementação de ações de SSR em serviços de APS, no SUS, no estado de São Paulo (SP), foi desenvolvida avaliação que adota a teoria do trabalho em saúde e a integralidade como referenciais, e utiliza banco de respostas de 2735 serviços ao questionário QualiAB - Avaliação da qualidade da Atenção Básica em Municípios de SP, em 2010. Construiu-se um modelo teórico da avaliação de práticas de SSR na APS - compreendendo os domínios promoção à SSR, prevenção e assistência às doenças sexualmente transmissíveis (DST)/aids, e atenção à saúde reprodutiva, com 25, 43 e 31 indicadores, respectivamente. As respostas dos serviços apontam: pré-natal com início e exames adequados, melhor organização para puerpério imediato do que tardio, planejamento reprodutivo seletivo para alguns contraceptivos; prevenção baseada em proteção específica, limites na prevenção da sífilis congênita, no tratamento de DST, no rastreamento do câncer cervical e mamário; atividades educativas pontuais, com restrita abordagem das vulnerabilidades, e predomínio do enfoque da sexualidade centrado na reprodução. A média geral de desempenho em SSR é 56,84%. O domínio atenção à saúde reprodutiva tem maior participação, seguido por prevenção e assistência das DST/aids e promoção à SSR (teste de Friedman estimou a contribuição no escore; Dunn, a participação relativa). Os três domínios são correlacionados (Spearman > 0,5). Técnica de agrupamento por k-médias mostrou 5 grupos de desempenho: A, B, C, D e E, compostos por 675, 811, 346, 676 e 227 serviços, com médias de 74,71; 61,95; 55,19; 45,57; e 21,56%, respectivamente. Arranjos organizacionais com saúde da família, ou saúde da família com Unidade Básica de Saúde; localização urbana periférica; delimitação da área de abrangência por planejamento; uso de dados de produção e epidemiológicos para organização do trabalho; presença de serviço especializado de atenção à aids no município, são variáveis associadas ao pertencimento do serviço de APS ao grupo A. Ajustadas em modelo de regressão logística, duas variáveis se apresentam independentemente associadas à maior chance de o serviço pertencer ao grupo A: uso de dados de produção e de dados epidemiológicos para organização do trabalho. Os resultados indicam que a implementação das ações de SSR na APS paulista é incipiente e corroboram a hipótese do reconhecimento inadequado da SSR como objeto de trabalho na APS; bem como de definição inapropriada das tecnologias, que limitam a tradução operacional do programa de SSR. Faz-se necessário: rever o objeto SSR para a APS, enfatizando sua abordagem integral; disseminar tecnologias de atenção à SSR; investir em capacitações, sobretudo, de gerências realmente técnicas; e ainda, fortalecer redes regionais temáticas para SSR. O modelo teórico da avaliação construído mostra-se viável e pode ser utilizado em futuras avaliações / The concept of sexual and reproductive health (SRH) gains visibility in the 1990s, a decade characterized by social activism and by the IV International Conference on Population and Development and the IV World Conference on Women, which affirm that primary health care (PHC) is a priority. In Brazil, PHC is considered strategic for the implementation of SRH in the Unified Health System (Sistema Único de Saúde - SUS). An evaluation was developed with the purpose of assessing the implementation of SRH actions in PHC at the SUS units in the state of São Paulo (SP), adopting the theory of work in health and comprehensiveness as references and using response database from 2735 units to the Questionnaire PHC Quality Evaluation in SP Municipalities - QualiAB in 2010. A theoretical model of evaluation for SRH actions in the PHC was designed - comprising the following domains: SHR promotion, prevention and assistance of sexually transmitted disease (STD)/AIDS, and reproductive care, with 25, 43 and 31 indicators, respectively. The responses from the units indicate: early start of antenatal care with proper test delivery, more effective organization for immediate postpartum than for late postpartum, and selective reproductive planning for some contraceptives; predominance of specific protection actions, limits in prevention of congenital syphilis, STD syndromic treatment and cervical and breast screening; occasional education activities with a restricted approach to vulnerabilities, an approach to sexuality predominantly through reproduction. The general performance score for dimension SRH at the units is 56,84%. The Reproductive care domain has a bigger participation in the general score, followed by STD/AIDS prevention/assistance and SRH promotion (Friedman test estimated contribution to the general score; Dunn, relative participation). The three domains are correlated (Spearman > 0,5). K-means clustering method showed 5 performance groups: A, B, C, D and E, consisting of 675, 811, 346, 676 and 227 units, with an average of 74,71; 61,95; 55,19; 45,57; and 21,56%, respectively. Organizational arrangements for work in PHC with family health, or the traditional health center combined with family health; urban outskirts, delimitation of area through management criteria; use of epidemiological and production data for work organization; specialized AIDS care in the municipality, are variables associated with PHC units taking part in group A. Adjusted in logistic regression model, two variables are independently associated to a higher chance of the unit to belong to group A: use of epidemiological and production data for work organization. The results indicate that the implementation of SRH services in PHC in the state of São Paulo is incipient and corroborate with the hypothesis of inadequate recognition of SRH as a PHC object of work; as well as inappropriate definition of technologies, which limit the operational translation of the SRH program. It is necessary to: review the SRH object for the PHC emphasizing its comprehensive approach; disseminate technologies of SRH care; invest in training, mainly in technical management, as well as strengthen thematic regional networks for SRH. The theoretical evaluation model designed is feasible and can be used in future evaluations

The study has two separate but related aims, which are to explore the social and health experiences of men who are in polygynous relationships and to develop holistic health and social strategies to support men who are in polygynous relationships. Objectives of the study were to identify the different permutations of polygynous relationships that related to health and social issues; to clarify the social status of men who are in polygynous relationship; to explore and describe the health experiences of men in polygynous relationship; to explore and describe the social experiences of men in polygynous relationship; to explore the spiritual experiences of men who are in a polygynous relationship; to describe and to generate holistic strategies to support men who are in a polygynous relationships. Method: In this study, the researcher used descriptive and interpretive phenomenological processes to develop a range of holistic strategies to support men who were in polygynous relationships. The researcher described the experiences and developed interpretations based on the lived experiences that the men reported. Findings: Polygyny remains the reality within the Bapedi tribe in Sekhukhune area. The practice of polygyny is not only for the affluent as indicated in most literature but is also practiced as a corrective strategy for families who are experiencing marital problems. Polygyny is not viewed as abusive to the women and children but rather beneficial to the women. It helps to reduce the risks of the development of cervical cancer that is predisposed by frequency of sexual intercourse. Polygyny promotes the morals within the communities, as children grow up within the two parents’ environment as opposed to the rising numbers of single parent families. Polygyny practice in the Sekhukhune areas is a voluntary choice and not a forced marital arrangement. Conclusions and recommendations: The researcher recommended policy guidance to support health practitioners with strategies to assist members of polygynous families in need of help. The policy also guides employers to recognise and to register the second or third wife as beneficiaries of the working husband. / Health Studies / D. Litt. et Phil. (Health Studies)

Jordan has a higher fertility rate (3.8) than the averages of countries similar in income to Jordan (2.2) and compared to the Middle East and North Africa region as a whole (2.8) (WHO, WB, UNICEF, & DHS, 2011). The findings of the 2009 Jordanian Population and Family Health Survey demonstrated that the total fertility rate (TFR) has stopped declining in the country since 2002 (DOS, 2010b; USAID, 2010). The prevalence of contraceptive use has also shown little change in Jordan over the last decade (DOS, 2010b; USAID, 2010). Given that contraception is one of the proximate determinants of fertility (Rahayu et al., 2009), the main purpose of this study was to investigate which factors are contributing to women's current contraceptive behavior and intention for future contraceptive use. Research questions were developed in a comprehensive framework that considers women's intention and actual behavior as outcomes of various interactive factors within a socio-cultural context. In particular, the study's framework was directed by a theoretical basis adapted from Ajzen and Fishbein's Theory of Reasoned Action (TRA) and an extensive review of the available literature in the research area. Obviously, the social set-up and cultural norms in the study setting, together with attitudes toward children and family, represent a traditional scenario that could help explain the consistency of fertility and contraceptive use in the country. Further, the influences of background characteristics on women's contraceptive behaviors and intentions provide another scenario that could help assess the current situation of family planning (FP) in Jordan. In this study, demographic factors, spousal communication variables and healthcare system-related factors are all defined as background characteristics. Attitudes and social norms reflect the women's behavioral determinants and represent the main constructs of the TRA. In fact, involving a set of factors related to women's beliefs and social norms in the study's framework provided an opportunity to explore how these factors might promote or inhibit a woman's intentions and behaviors in respect to contraceptive use. In a three-manuscript format, this research was designed to achieve a number of objectives. The first manuscript aimed at identifying the major factors associated with the current use of contraception among women of childbearing age in northern Jordan. The second manuscript focused on investigating the main factors that are associated with women's contraceptive method preference (e.g. the choice of modern contraceptives as effective methods in preventing pregnancy versus the choice of traditional contraceptives as methods with high failure rates). The third manuscript attempted to explore the key factors associated with women's intention for future contraceptive use since the existence of such an intention would consequently translate into an actual behavior later. In 2010, original cross-section data were collected by means of a face-to-face interview using a structured pre-tested survey. The study sample included women who were currently married and were between 18 and 49 years old. Applying a systematic random sampling procedure, all respondents were recruited from the waiting rooms of five randomly selected Maternal and Child Health (MCH) centers in the Governorate of Irbid, northern Jordan. Using a list provided by the Ministry of Health, all centers in the Governorate were stratified according to the region (urban vs. rural) and randomly selected in proportion to their number in each region. The final sample size for this research consisted of 536 women surveyed, giving a response rate of 92.4 percent. Utilizing logistic regression analyses, the results of the dissertation manuscripts indicate that women's behaviors and intentions toward the use of contraception are affected by a number of factors at the individual, familial and institutional levels. The findings that emerged from the three manuscripts provide health professionals and policy makers with important information to assist in the design of FP programs and campaigns aimed at increasing current contraceptive use, enhancing the adoption of modern contraception and motivating the intention for future contraceptive use. This research strongly suggests that health professionals develop health policies that both expand the availability of MCH centers and strengthen the role of healthcare providers to dispel the numerous rumors and misconceptions surrounding the use of contraceptives, particularly modern ones. Health workers at the MCH centers need to ensure that women have sufficient information about the benefits and side effects of different types of contraception by offering proper FP counseling. The messages that religious leaders can use in advocating for FP would also help make contraceptive use socially acceptable since their opinions are often followed by the majority. This would be a key step toward removing the barriers to contraceptive use. Moreover, to design effective FP interventions, planners should take into account women's attitudes toward the use of contraceptive methods and the components of those attitudes (e.g. women's approval of contraceptive use for birth spacing and perceptions regarding the value of large family sizes and the importance of having male children in Jordanian families). / Graduation date: 2012 / Access restricted to the OSU Community at author's request from May 9, 2012 - May 9, 2013