A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / Health literacy is the degree to which individuals have the capacity to understand basic health information and services needed to make appropriate health decisions. Women seen at Maricopa Integrated Health System (MIHS) Refugee Women’s Health Clinic (RWHC) are routinely offered education on developing a Reproductive Life Plan (RLP). In order to influence women’s reproductive health and medical decision‐making, there is a need to tailor RLP counseling to engage their male partners in the refugee community. We aimed to assess increased knowledge on preconception care related to the importance of developing a RLP, perspectives on birth spacing, and the influence of men as well as religion in medical decision‐making. We aimed to identify the refugee community’s receptivity to culturally and linguistically appropriate audiovisual modalities. Study participants comprised 120 refugees (39 men and 81 women) including couples, across the respective target languages with pre‐ and post‐Likert scale surveys assessing perspectives on RLP, birth spacing, the role of religion, and readiness for behavior change. Summary statistics examined changes in pre‐ and post‐Likert scale survey responses with responses dichotomized as Strongly agree/Agree compared against all other responses. A higher frequency of male respondents agreed about knowing what RLP means in the posttest relative to pretest (71.8% to 89.7%, P = 0.016) as well as 'Not having children…' (41% to 64.1%, P=0.035). Female respondents were more likely to agree to 'Know what RLP means' (76.5% to 86.4%, P =0.039) and 'Having a baby soon after…' (65.4% to 76.5%, P =0.035) after the training. They also were less likely to agree that 'RLP is about birth control' (71.6% to 59.3%, P =0.021). Amongst Muslim participants, we found improvement in knowing what RLP means (65.5% to 87.9%) and that it is important for men to have a RLP (67.2% to 84.5%). Cronbach’s alpha was used to measure internal inconsistency, with most values less than 0.5 and deemed unacceptable. Only one value, birth spacing, was > 0.6 and deemed questionable. There was the same degree of concordance, yet there also was discordance in the direction of opinions between women and men pre vs post‐test answers. When comparing couples pre and posttest, there was no significant differences observed across genders. This is the first reported U.S. initiative to provide a culturally and linguistically appropriate preconception health education. Project had demonstrated ability to mobilize several ethnic communities around the RLP. Respondents among both genders were more likely to agree about knowing what RLP means. The most challenging aspect of our community mobilization efforts was recruiting a larger sample size. Another limitation was the use of the Likert scale in a population with low literacy as there were some discrepancies in responses to negatively‐worded questions. Future studies could use a visual analog scale of smiley faces to assist those with limited literacy and incorporate a more global feel.

The purpose of the study was to examine reproductive life planning practices among Title X family planning health care providers and clinical staff. Reproductive life planning is a program priority for Title X clinics, those that receive federal money for providing family planning services to low-income women and men. The goal of reproductive life planning is to decrease unwanted and unintended pregnancies and improve preconception health care however; this practice has not been described. First, a conceptual analysis was conducted to create a definition of reproductive life planning that was consistent with the literature. Reproductive life planning is a process that is centered on reproductive and other life goals and is personalized, collaborative, fluid, and focused on health-promotion. Second, a mixed methods design was used to examine reproductive life planning practices and qualitative interviews were conducted to explore barriers and facilitators to implementing reproductive life planning practices. Data were obtained from health care providers and clinical staff employed at Title X clinics in Illinois, Iowa, Minnesota, Missouri, Nebraska, and North Dakota. A total of 148 clinicians completed a web-based survey which was analyzed to describe which types of patients, the topics covered, and the frequency with which reproductive life planning was discussed during an office visit. Surveys were then examined to identify 20 providers to conduct qualitative interviews with to further explore reproductive life planning practices. The qualitative interviews were also performed to explore the barriers and facilitators clinicians face to practicing reproductive life planning. The results of the web-based questionnaire were examined mainly with medians and frequencies to examine reproductive life planning practices. Qualitative interviews were coded using a content analysis approach to two aims; one to examine how reproductive life planning was using during clinic visits and two, to identify the barriers and facilitators clinicians face when discussing reproductive life planning with patients. Findings from the survey and the interviews suggest that most clinicians are discussing pregnancy intentions with their patients. However, from the interviews, three types of scope of reproductive life planning emerged; those clinicians who screened their patients’ pregnancy intentions, those who planted the seed in the patient’s mind, and those who explored the context of a patient’s life and their goals to contextualize how pregnancy and childbearing would fit into their lives in order to clarify pregnancy intention and move toward the corresponding health behaviors. It is argued that the third group of providers is using reproductive life planning as intended by experts. Finally, barriers to RLP discussions were examined as well as approached providers used to overcome the barriers. In conclusion, many clinicians are practicing reproductive life planning as intended, however many are not. Improved training and protocols are needed to ensure clinicians are providing their patients with the best reproductive life planning discussions. Additionally, systemic structures, like access to quality family planning services, need to be improved to aid clinicians in helping their patient plan their families.

Mycket pekar på att det finns en brist hos många svenska unga kvinnor vad gäller kunskap om fertilitet och reproduktion. Det finns ett behov av att formulera ett evidensbaserat redskap för barnmorskor att använda sig av i samtal om en Reproduktiv Livsplan och för att ge hälsoförebyggande information inför en eventuell graviditet. Syfte: Studiens syfte var att genomföra en pilotstudie beträffande implementering av en Reproduktiv Livsplan i svensk vårdkontext. Ett andra syfte var att testa ett instrument och proceduren inför kommande forskningsprojekt samt att utvärdera dess effekt. Metod: Föreliggande studie hade en kvantitativ ansats och hade designats som en randomiserad kontrollerad interventionsstudie. Totalt deltog 75 unga kvinnor i tre grupper; interventionsgruppen (IG), kontrollgrupp 1 (CG1) och kontrollgrupp 2 (CG2). Data samlades in via enkäter vid baslinje och telefonintervju vid uppföljning. Av de 75 kvinnorna var det 70 som fullföljde studien. Resultat: Få kvinnor uppgav att de tidigare hade funderat speciellt mycket på frågor kring fertilitet. Kunskapen om reproduktion och fertilitet var jämn mellan grupperna vid baslinjemätningen. Vid uppföljningen visade resultaten en kunskapsökning bland den tredjedel av kvinnorna som tagit del av interventionen. Det mest utmärkande fyndet var att flertalet av kvinnorna i interventionsgruppen var ganska eller mycket positiva till att barnmorskan frågade dem om deras Reproduktiva Livsplan. Alla kvinnorna svarade att det var ganska eller mycket sannolikt att de skulle vända sig till sin barnmorska om de hade fler frågor angående fertilitet. Flertalet ansåg att vårdpersonal borde ha som rutin att diskutera frågor om en Reproduktiv Livsplan. Slutsats: Det finns ett behov av att formulera ett evidensbaserat redskap för barnmorskor att använda sig av i samtal med unga kvinnor vad gäller deras Reproduktiva Livsplan och för att informera om hälsoförebyggande faktorer inför en graviditet. Genomförbarheten för denna studie var god och materialet väl lämpat för syftet, därmed kan det även rekommenderas för kommande forskning. Ytterligare visade det sig även att kvinnorna som deltog i interventionen ställde sig positiva till samtalet med barnmorskan om en reproduktiv livsplan. / Research indicates that there is a shortage among Swedish young women in terms of knowledge about fertility and reproduction. There is a need to formulate an evidence-based tool for midwives to use in conversation about a Reproductive Life Plan and to provide information about health prevention before a possible pregnancy. Objective: The aim of this study was to conduct a pilot study on the implementation of a Reproductive Life Plan in a Swedish caring context. A second aim was to test the instrument and procedure for future research projects and to evaluate its effect. Method: The present study had a quantitative approach and was designed as a randomized controlled intervention study. In total, 75 young women participated in three groups; intervention group (IG), control group 1 (CG1) and control group 2 (CG2). Data were collected via questionnaires at baseline and at follow-up by telephone interview. Out of the 75 women, 70 completed the study. Results: Few women reported that they had previously thought much about issues surrounding fertility. The knowledge of reproduction and fertility was similar between the groups at baseline. At follow-up there was a knowledge increase among the third of the women who took part of the intervention. The most striking finding was that most of the women in the intervention group were somewhat or very positive about the midwife asking them about their Reproductive Life Plan. All the women replied that it was somewhat or very likely that they would turn to their midwife if they had more questions about fertility. The majority felt that healthcare professionals should routinely discuss issues of a Reproductive Life Plan. Conclusion: There is a need to formulate an evidence-based tool for midwives to use in conversations with young women in terms of their Reproductive Life Plan and to provide information on health prevention factors before pregnancy. The feasibility of this study was good, and the material well suited for the purpose, thus it can be recommended for future research. Furthermore the results also showed that the women that participated in the intervention where positive to the talk they had with the midwife concerning the reproductive life plan.

En Afrique subsaharienne, le fardeau exact du cancer reste largement méconnu et sous étudié. La Gambie et le Mali sont parmi les rares pays d'Afrique à avoir des registres de cancer opérationnels basés sur la population. Les données allant de 1988 à 2006 pour la Gambie et de 1987 à 2009 pour Bamako-Mali, ont été utilisées afin d'analyser les taux d'incidence en fonction de l'âge, du sexe, de l'ethnicité et de caractériser les profils des femmes atteintes de cancers du sein et du foie. Les données ont été arbitrairement divisées en deux sous périodes ; 1988-1997 et 1998-2006 pour la Gambie et 1987-1997, 1998-2009 pour Bamako-Mali. En plus de ceci, une étude cas témoins sur les facteurs de risque associés à la vie reproductive des femmes atteintes de cancer du sein a été réalisée au Mali. Dans ces deux pays, le cancer du sein chez les femmes est caractérisé par une prédominance de cancers pré-ménopausiques. Ces femmes sont pour la plupart multipares et leur âge médian au moment du diagnostic est compris dans la tranche d'âge 40-45 ans. L'étude cas témoins a montré une association significative entre l'âge tardif aux premières règles et une augmentation du risque de développer un cancer du sein chez les femmes préménopausées contre une baisse du risque chez les femmes post-ménopausées (pas significatif). Pour ce qui est du cancer du foie, pendant que l'incidence de ce dernier était relativement stable chez les hommes de la Gambie, elle augmentait chez les femmes de ce même pays. Par contre au Mali, une baisse progressive et homogène dans l'incidence du cancer du foie a été observée au fil des ans et pour les deux sexes. Des études supplémentaires sont nécessaires afin de caractériser le profil biologique du cancer du sein et les facteurs de risque qui y sont associés, mais aussi afin d'évaluer le rôle de l'obésité et de l'exposition à l'aflatoxine B1 dans les tendances observées sur le cancer du foie en Afrique de l'Ouest / In Sub-Saharan Africa, the exact burden of cancer remains largely unknown and understudied. The Gambia and Mali are among the few African countries with operational population-based cancer registries. Data from 1988 to 2006 for the Gambia and from 1987 to 2009 for Bamako-Mali were used to analyze the incidence rates according to age, sex and ethnicity and to characterize the profile of women with breast and liver cancers. The data were arbitrarily divided into two periods, 1988-1997 and 1998-2006 for the Gambia and 1987-1997, 1998-2009 for Bamako- Mali. In addition to this, a case-control study evaluating the risk factors associated with the reproductive life of women with breast cancer was conducted in Mali. In both countries, breast cancer in women is characterized by a predominance of premenopausal cancers. These women are mostly parous with a median age at diagnosis in the age group 40-45 years. The case-control study showed a significant association between late age at menarche and increased risk of developing breast cancer in pre-menopausal women against a decrease in risk among post menopausal women. Concerning liver cancer, while the incidence rate was relatively stable among males in the Gambia, it was increasing among females of this country. In contrary, in Mali, a gradual decline and homogeneous in the incidence of liver cancer was observed over the years and for both sexes. Further studies are needed to characterize the biological profile of breast cancer and risk factors associated with it, but also to assess the role of obesity and exposure to aflatoxin B1 in order to understand the trends observed in liver cancer in West Africa

Despite an initiative to provide preconception care (PCC) and reproductive life planning (RLP) for all women of childbearing age, many women, especially those with low incomes, are not receiving it. As a result, there continues to be a high rate of infant morbidity and mortality in this population. Furthermore, low income adolescent females have not been adequately studied regarding this phenomenon. The purpose of this phenomenological study was to explore low income adolescent females' knowledge, attitudes, and beliefs about PCC and RLP in order to serve them more effectively. Five low income adolescent females, aged 18 to 21, were recruited through criterion sampling and they each engaged in 2 individual in-depth interviews. The health belief model, social cognitive theory, and adolescent affective and cognitive theory were the conceptual frameworks used to develop the interview guide, conduct the interviews, analyze the data, and formulate the recommendations for future studies. Moustakas's phenomenological interview process was used as a guiding framework to prepare and conduct the interviews. Qualitative data were analyzed using Moustakas's modified version of the Stevick-Colaizzi-Keen method of analysis. Findings were that participants (a) had no experiences with PCC or RLP, (b) lacked knowledge about preparing for pregnancy, (c) had negative interactions with medical personnel, and (d) wanted more information about PCC and RLP. Further research is recommended to examine current PCC/RLP practices, conduct additional PCC studies of adolescents, and develop culturally- and age-appropriate PCC programs. Findings from these studies could improve both the lives of the adolescents and the health of their offspring.

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal.

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal

Alors que dans les sociétés de l’Afrique de l’Ouest, le mariage représente traditionnellement le point de départ de la séquence des événements démographiques associés à la formation de la famille, aujourd’hui cette séquence s’est complexifiée. Suite à l’effritement des modes traditionnels du passage à l’âge adulte, les jeunes citadins reportent leur mariage, le contexte de l’initiation sexuelle est plus fréquemment prénuptial et le nombre de naissances hors mariage semble augmenter. Peu d’études se sont penchées sur l’analyse de la séquence de ces événements sous l’angle du parcours individuel. L’objectif central de ce mémoire est d’explorer, de décrire et d’expliquer les changements survenus dans les parcours d’entrée en vie féconde des femmes durant leur jeunesse en utilisant comme unité d’analyse l’entièreté des parcours. Utilisant les données EDS du Burkina Faso, nous synthétisons en parcours, sous forme des séquences d’épisodes, les calendriers du premier rapport sexuel, de la première union et de la première naissance. Avec l’analyse séquentielle, nous identifions quatre catégories de parcours : nuptial, sexualité prénuptiale, maternité prénuptiale et célibataires. La méthode permet également une catégorisation plus fine des parcours et une visualisation de modèles de transitions. Nous analysons ensuite l’association entre les caractéristiques individuelles et les parcours suivis grâce à des modèles multinomiaux. Nos résultats confirment l’augmentation des parcours non nuptiaux auprès des jeunes. De plus, ils montrent qu’un niveau de scolarité plus élevé augmente la probabilité de suivre un parcours non-traditionnel, notamment chez les femmes urbaines, le milieu de socialisation à l’enfance ayant aussi un effet sur le choix du parcours. / In West African societies, marriage has traditionally represented the first step of the sequence of demographic events regarding the formation of the family. Currently, this sequence has become more complex. Following the erosion of traditional patterns of entrance into adulthood, urban youth tend to delay marriage, to increasingly engage in premarital sex while premarital births among youth seem to rise. Our study considers demographic life courses of entry into reproductive life as individual sequences of states. The main purpose of this study is to explore, describe and explain changes in young women’s sequences of entry in reproductive life using individual sequences as the unit of analysis. Using data from the 2003 Demographic and Health Survey of Burkina Faso, we synthesize the timing of first sexual intercourse, first union and first birth into sequences. Using Sequence Analysis methods, we identify four main categories of entrance in reproductive life: marital, premarital sex, premarital childbearing and singles. These methods allow a finer classification and a visualization of complete sequences and their transition patterns. We then analyze the association between individual characteristics and the sequence that women follow. Our results confirm that non-traditional sequences rise among younger generations. We also show that while women’s years of instruction increase, the probability of starting a sequence by premarital sex rises and the probability of starting a sequence by a marriage falls dramatically. Finally the childhood place of residence seems to moderate these effects by increasing the probability to follow a non-traditional sequence for urban women. / En las sociedades del Africa subsahariano el matrimonio representa tradicionialmente el inicio de la secuencia de eventos demográficos asociados a la formación de la familia, pero esta secuencia ha sufrido transformaciones. Como consecuencia de la erosión de los modelos tradicionales del paso a la edad adulta, los jovenes citadinos tienden a retardar el casamiento, el contexto de la primera relación sexual es cada vez mas prenupcial y los nacimientos prenupciales han aumentado. Pocos estudios han analizado la secuencia estos eventos bajo la perspectiva del curso de vida individual. El objetivo central de este estudio es explorar, describir y explicar los cambios en la secuencia de la entrada a la vida fecunda empleando las secuencias de episodios completas como las unidades de análisis. Utilizando los datos de la EDSBF-2003, sintetizamos en secuencias individuales los calendarios de la primera relación sexual, de la primera unión y del primer nacimiento. A traves del análisis secuencial, identificamos cuatro tipologías: nupcial, sexualidad prenupcial,maternidad prenupcial y solteras. Obtenemos una clasificación mas fina de las secuencias al visualizar distintos modelos de transición. Empleando un modelo multinomial analizamos la asociación entre las características de los individuos y las secuencias. Nuestros resultados confirman que las secuencias no nupciales ganan terreno en las generaciones mas jóvenes. Además, un nivel de escolaridad mas elevado aumenta la probabilidad de empezar una secuencia con una relación sexual. El medio de socialización en la infancia modera estos efectos, ya que las mujeres urbanas tienen una probabilidad mas elevada que las rurales de seguir una secuencia no nupcial.

No description available.