Pregnancy and motherhood are natural processes in the lives of women of reproductive age. These processes are generally considered to be positive and fulfilling experiences. However, for various reasons, many women end up dying as a result of these processes. Improving maternal health and reducing maternal mortality are accepted as human rights challenges and prioritized in several international declarations and national policies. However, progress in achieving these objectives still remains poor. This thesis aims to explore the maternal health and healthcare in the Indian state of Madhya Pradesh through a human rights lens. A human rights lens provides a framework to study various aspects of the problem of maternal health from a human rights perspective. It helps in highlighting the gaps and challenges related to political priority, sociocultural, economic and individual-level factors and the availability, accessibility, acceptability and quality of maternal healthcare services. A combination of quantitative and qualitative research methodologies was applied in four sub-studies conducted in Madhya Pradesh. The specific objectives were: to investigate, by using John W. Kingdon’s multiple-streams model of agenda setting, why and how maternal health became a political priority in the state (Paper I); to estimate the effects of individual-, community- and district-level characteristics on the utilization of maternal health services with special reference to antenatal care, skilled attendance at delivery and post-natal care (Paper II); to analyse sociocultural and service delivery related dimensions of maternal deaths in rural central India through a human rights lens (Paper III); and to evaluate the technical efficiency of the public district hospitals using data envelopment analysis (Paper IV). The findings of the first qualitative study indicated that various developments at international, national and state level brought the issue of maternal health to the priority political agenda in Madhya Pradesh state. This resulted in the introduction of new policies and programmes and more resources were allocated for improving maternal health. However, several challenges still remain in ensuring proper implementation of these programmes and policies. The quantitative study on factors affecting the use of maternal health services revealed that 61.7% of women used antenatal care at least once, 49.8% of women used skilled attendance at delivery and 37.4% of women used post-natal care during their most recent pregnancy. The household’s socio-economic status and mother’s education emerged as the most important factors associated with the use of antenatal care and skilled attendance at delivery. Delivery by skilled personnel and the use of antenatal care were the most important factors in the use of post-natal care. This study highlighted the need to identify and focus on community- and district-level intervention along with addressing the individual-level factors. The findings of the third qualitative sub-study revealed that all pregnant women in the study tried to access medical assistance for obstetric complications but various factors delayed appropriate care. The underestimation of complication symptoms by family members, gender inequity and the negative perceptions regarding delivery services deferred decisions to seek care. Transportation problems and care seeking at multiple facilities also constrained timely reaching of appropriate health facilities. Negligence by health staff in providing care, and unavailability of blood and emergency obstetric care services, delayed the receiving of adequate care after reaching a health facility. This study indicates that normative elements of a human rights approach to maternal health, i.e. availability, accessibility, acceptability and quality, were not fully upheld. The deceased women and their relatives were unable to claim their entitlements and the duty bearers could not meet their obligations despite their conscious efforts to improve maternal health. In the last study, the results of data envelopment analysis revealed that half of the district hospitals (20) in the study were operating inefficiently. This research establishes a need to give special attention to addressing challenges in the maternal health programmes at the implementation level as well as tackling the social determinants of maternal health. In order to increase the utilization of maternal health services in the state, the need to identify and focus on community- and district- as well as individual level interventions is emphasized. In order to prevent maternal deaths, a need for further concentrated efforts is underlined with a view to honouring human rights elements of maternal health by better community education, women’s empowerment and health system strengthening with the provision of appropriate and timely services including emergency obstetric care of good quality. It also highlights a need to identify the causes of the observed inefficiencies and to take appropriate measures to increase the efficiency of district hospitals.

Sexualitetens och den sexuella hälsans betydelse för människans välbefinnande är väl dokumenterad. Emellertid visar forskning att kvinnor med cancerdiagnos inte får den hjälp de önskar av sjukvården gällande sexuell hälsa. Detta faktum accentuerar behovet av att förstå vilka mekanismer som ligger bakom. Studiens syfte var att identifiera hinder och förutsättningar för samtal om sexuell hälsa mellan sjuksköterskor och kvinnor med cancerdiagnos. Studien utformades som en litteraturöversikt med kvalitativa studier. I resultatet identifierades ett antal hinder och förutsättningar för samtal om sexuell hälsa, vilka delades in i fem kategorier: vårdorganisationens betydelse för samtal om sexuell hälsa, vårdpersonalens utbildning i relation till samtal om sexuell hälsa, vårdpersonalens förmåga att undervisa och informera, rädslor och känslor inför samtal om sexuell hälsa, och attityder till och ignorans inför samtal om sexuell hälsa. Studien har visat att rädslor inför att tala om sexuell hälsa, sjuksköterskors brist på utbildning och tid är det som utgör hinder för samtal om sexuell hälsa. Förutsättningarna för samtal identifierades som utbildning och erfarenhet hos vårdpersonalen samt att ämnet adresserades av kvinnorna med cancerdiagnos. / The importance of sexuality and sexual health for human well-being is well documented. However, research shows that women diagnosed with cancer experience the care they retrieve related to these issues to be insufficient. This fact highlights the need of insight into underlying causes and mechanisms. The purpose of this study was to identify barriers and preconditions to communication of sexual health issues between nurses and women diagnosed with cancer. A review of qualitative, interview-based research was conducted. A series of barriers and preconditions to communication on the sexual health topic was identified and categorized into 5 groups: Organization of health-care, Educational level of staff, Care giver´s ability to teach, Fears and feelings, and Attitudes and ignorance. This review concludes fear of addressing conversation, nurse´s lack of education and time for patients to be the most obstructive elements. Education and experience of staff, and that women diagnosed with cancer addressed the subject was identified as preconditions.

Bakgrund: Diabetes mellitus är en av vår tids stora folksjukdomar och antal drabbade ökar för vart år. Sjukdomen kan innebära funktionsnedsättningar som kan få en negativ inverkan på patientens sexuella hälsa. Sexualitet och sexuell hälsa är viktigt för människans livskvalité. Detta är de flesta sjuksköterskor medvetna om, dock är det få som tar sig tid att ta upp ämnet med patienter med diabetes. Syfte: Att belysa vilka faktorer som påverkar den sexuella hälsan hos personer med diabetes, samt vilket stöd sjuksköterskan kan ge patienten. Metod: Studien som gjorts är en litteraturöversikt över de sexuella problemen relaterade till både män och kvinnor med diabetes. Resultat: Resultatet visade att diabetes i stor grad påverkade den sexuella hälsan negativt hos både män och kvinnor med diabetes. De fysiska faktorerna som påverkas är smärta vid samlag, förmågan att få orgasm, minskad känsel, trötthet, för kvinnor nedsatt lubrikation och för män problem med erektionen. De psykiska faktorerna som påverkas är; nedsatt lust, tillfredsställelse, sexuell upphetsning och minskad njutning. Slutsats: Kvinnor och mäns sexualitet drabbas generellt i lika stor grad av sjukdomen, men problemen tar sig olika uttryck. Kvinnor drabbas i mycket större utsträckning av sexuella dysfunktioner av mer psykisk karaktär, medan män oftare lider av problem som är relaterade till fysiska faktorer. Klinisk betydelse: Resultatet visar att det finns tydliga brister i sjuksköterskans kunskap kring hur diabetes mellitus påverkar sexualiteten. Vidare att mer utbildning behövs generellt om sexualitetens betydelse för patientens välmående i sjuksköterskans grundutbildning. / Background: Diabetes mellitus is one of the most common diseases of our times and the number of persons suffering from it increases each year. The condition can mean disabilities that can affect the sexual health of patients negatively. Sexuality and sexual health are important for humans’ quality of life. This is something most nurses are aware of, however it’s only a few who takes the time to raise the subject with patients with diabetes. Aim: To explore factors that affect the sexual health of patients with diabetes and the support the nurse can give to the patient. Method: The study is a literature review of the sexual problems related to both men and women’s diabetes. Result: Diabetes had negative effects on the sexual health of men and women with diabetes. Example on physical factors that gets affected is pain during intercourse, ability to have an orgasm, reduced sensation, for women reduced lubrication and for men erectile problems. The psychological factors that get affected are; reduced desire, satisfaction, sexual arousal and enjoyment. Conclusion: Women and men’s sexuality suffer generally in the same degree from the disease, but the problems appear differently. Women suffer more from sexual dysfunctions of psychological characteristics, while men more often suffer from problems related to physical factors. Clinical significance: The result shows that there is a clear insufficiency among the nurses knowledge about how diabetes affects the sexuality. Further on that more education is needed about sexuality’s effect on the patients’ well-being.

Background: Ovarian cancer affects many women worldwide. Tumors that grow in the genitalia and pelvis have because of its placement a large threat to the sexual ability. Treatment for ovarian cancer may lead to the sexual possibilities inhibited. Sexual health is a state of physical, mental, emotional and social well-being related to sexuality. Sexual health can be experienced in spite of disease, dysfunction or infirmity. Aim: The aim is to describe the factors that influence women's sexuality after treatment for ovarian cancer Method: A literature review, in which seven quantitative and three qualitative articles were analysed. Result: From the analysis revealed two main themes; Physical changes and Mental changes. Physical changes were divides into two subthemes; Changes in sexual function and Menopause and reproductive ability. Mental changes were divided into three subthemes; Decreased desire and the relationship with the partner, The relationship with one's own body and The lack of information from health care professionals. Conclusion: Women with ovarian cancer experience a lack of information from health care professionals about what can be expected to happen with the sexual function after treatment. It is important that the nurse recognizes this need and understands that sexual health can be experienced despite illness. / Bakgrund: Äggstockscancer drabbar många kvinnor världen över. Tumörer som växer i genitalier och bäcken utgör på grund av sin placering ett stort hot mot den sexuella förmågan. Behandling för äggstockscancer kan leda till att de sexuella möjligheterna hämmas. Sexuell hälsa är ett tillstånd av fysiskt, mentalt, känslomässigt och socialt välbefinnande relaterat till sexualitet. Sexuell hälsa kan upplevas trots sjukdom, dysfunktion eller funktionshinder. Syfte: Syftet med studien är att beskriva vad som påverkar kvinnors sexualitet efter behandling för äggstockscancer. Metod: En litteraturöversikt där sju kvantitativa och tre kvalitativa artiklar analyserades. Resultat: Av analysen framkom två huvudteman; Fysiska förändringar samt Psykiska förändringar. Fysiska förändringar med subtemana; Förändrad sexuell funktion samt Menopaus och reproduktiv förmåga. Psykiska förändringar med subtemana; Minskad lust och relationen till partner, Relationen till den egna kroppen samt Bristen av information från sjukvårdspersonal. Slutsats: Kvinnor med äggstockscancer upplever brist på information från sjukvårdpersonal om vad som kan förväntas hända med den sexuella funktionen efter behandling. Det är viktigt att sjuksköterskor uppmärksammar detta omvårdnadsbehov och förstår att sexuell hälsa kan upplevas trots sjukdom.

Since 1999, youth have experienced an increase in HIV incidence. Gay male youth, in particular, are a priority sub-population because they accounted for the highest exposure category in 2008 among youth. Due to the lack of studies on gay male youth who are susceptible to HIV, and the reality that most previous research on stigma may no longer reflect the contemporary context, nursing based research was undertaken. Utilizing critical theory, stigma within the therapeutic relationship was investigated through eight semi-structured interviews with gay male youth who were recruited through a gay men’s sexual health clinic in Ottawa, Canada. The results of this research showed that while stigma, whether perceived stigma or the fear of stigmatization, was still felt by these participants in some interactions, overall, these youth had positive experiences with the health care system, particularly within the context of the gay men’s sexual health clinic.

När tonåringar utvecklar sin syn på sexualitet och samlevnad behöver de vuxenvärldens stöd och vägledning. Denna period av en människas liv präglas av upptäckande och utforskande vilket gör det betydelsefullt att ungdomar tillskansar sig kunskaper och utvecklar förståelse som bidrar till att de fattar hälsosamma beslut. Skolan fyller en viktig funktion i arbetet med att försöka ge alla ungdomar samma möjligheter till en god sexuell hälsa och är således en självklar arena för hälsofrämjande arbete. Syftet med denna studie är att ta del av pedagogers upplevelser av att undervisa inom sex- och samlevnad. Datainsamlingen genomfördes i form av sex semistrukturerade intervjuer med pedagoger inom olika undervisningsämnen på olika högstadieskolor i två kommuner. Resultatet tyder på att det finns en gemensam uppfattning om att sex - och samlevnadsundervisningen i skolan är viktig och dessutom antas ha positiva effekter för elevers sexuella hälsa. Det framgår dock att det förekommer skillnader i pedagogernas upplevelser av att kunna arbeta med sex – och samlevnad på ett strukturerat, medvetet och kreativt sätt. Hemmet och skolan beskrivs som två viktiga arenor. Föräldrar verkar ha en tilltro till pedagogers kompetens och pedagogerna själva tar sitt uppdrag som upplysare och vägvisare på stort allvar. / When teens develop their views on sexuality and relationships they need adult support and guidance. This period of a person's life is marked by discovery and exploration. Therefore it is important for young people to gain knowledge and develop understanding that contributes to making healthy decisions. The school plays an important role in efforts to try to give all young people the same opportunities for good sexual health education and is an obvious environment for health promotion. The purpose of this study is to take part of educators experiences of teaching in sex education. Data collection was conducted in the form of six semi-structured interviews with teachers in various subjects and at different secondary schools. The results suggest that there is a common perception that sex - and coexistence education in schools is important and assumed to have positive effects on students sexual health. However, it appears that there are differences in teachers' perceptions of being able to work with sex education in a structured , conscious and creative way. The home and the school are described as two important arenas . Parents seem to have a belief in teachers' skills and the teachers themselves take their mission as educators and guides very seriously.

Uganda has a predominantly young population, and there is a need for targeted HIV/AIDS prevention programming. Peer education is a health intervention style that has been used with appreciable success in adolescent groups, but some issues exist. We hypothesize that more can be done in the program planning stages to increase the chances of sustained success, and have completed two different types of cross-sectional analyses to investigate this aspect. We used Social Network Analysis to examine the social structure of two secondary schools in Fort Portal, Uganda. We identified existing modes of influence and natural channels of communication, and used these to create a feasible model of peer educator selection. We also studied present levels of communication about sexual and reproductive health within youth relationships, and found that youth are willing to talk to their friends, but high levels of communication do not generally occur. This provides an important point of entry for health promotion programs. / Population Health

Good sexual and reproductive health is fundamental to the overall health status of Māori communities. In 2001, the Ministry of Health reported that New Zealand was facing a Chlamydia epidemic. This epidemic has not abated as rates of Chlamydia have increased significantly in the past five years, with disproportionately high rates in young Māori women compared to non-Māori women. Despite significant sexual health disparities, young Māori have had limited opportunities to participate in research focussed on sexual health and voice their opinions and concerns on sexual health issues. This qualitative descriptive study has used a Māori inquiry paradigm and approached the research from a Kaupapa Māori perspective. The primary research question asked what the knowledge, attitudes and reported behaviours of young urban Māori women were in regards to sexual health and in particular, the sexually transmitted infection Chlamydia. Secondary aims were to ascertain the sources of information used and accessibility of sexual health services, as well as identifying resilience factors associated with protection against Chlamydia infection. The data was collected from semi-structured interviews with 16 young Māori women living in the Auckland region. Data analysis involved the inductive approach of categorical content analysis to identify major categorical themes to answer the specific questions posed. The main conclusion was that there are a number of barriers to accessing quality sexual health information and services for young Māori women. Participants’ level of knowledge varied reflecting their personal experiences and many were unaware that Chlamydia is asymptomatic and that delayed diagnosis can lead to fertility problems. The main sources of sexual health information accessed were whānau, peers, school, and contact with health professionals. Racism was identified as one of the barriers to sexual healthcare services. The young women expressed a clear preference for sexual health services to be delivered by Māori. Most importantly, for sexual health interventions to be successful it is essential that Māori communities, including young people and their whānau, are an integral part of creating positive solutions. Resilience factors that may help protect young women from contracting chlamydia characteristic of this group were having a strong connection with a caring adult or friend and parents who viewed sexuality as a normal part of adolescent development. In addition, having a positive Māori cultural identity with an ability to understand bicultural differences was strongly associated with participants accessing sexual healthcare services despite identified barriers.

This thesis documents my research on the epidemiology of Human Immunodeficiency Virus (HIV), hepatitis C virus (HCV) and other transmissible infections among 'at risk' young people, injecting drug users and sex workers in inner Sydney, and how this contributed to the early understanding of these infections in these potentially vulnerable populations in Australia. It also demonstrates how this work informed the development of innovative health service models in Sydney??s Kings Cross, including the Kirketon Road Centre (KRC) and the Sydney Medically Supervised Injecting Centre (MSIC), to address the public health risks affecting these populations over time. Sub-themes include the establishment of sentinel surveillance systems at KRC to monitor HIV and HCV prevalence and incidence as well as trends in drug use in these populations, considered to be key drivers of these epidemics in Australia. Another sub-theme is the clinical trials of pharmacotherapies for both opioid and psychostimulant dependence and the development of the dual treatment approach to HIV (and later HCV) and drug dependence that built upon this. KRC has been an exemplar of this approach, which has been shown to enhance treatment adherence among people who inject drugs ?? necessary to achieve treatment outcomes comparable to other affected populations. In more recent years my research has also included a focus on the epidemiology, physiology and treatment of opioid overdose and other injecting-related harms among IDUs. Underlying my work over the past 20 years has been my commitment to the social justice belief that health is a basic human right and that these socially marginalised populations should have equitable access to high quality evidence-based health care.

Thesis (M.S.)--University of North Texas, Dec., 2007. / Title from title page display. Includes bibliographical references.