This thesis investigates the understanding of health needs of women in rural Nepal using a participatory action research (PAR) framework. This framework was evaluated using a multiple case study design. The cases were women's groups being observed and researched by the researcher. The thesis is concerned with developing and evaluating the PAR methodology and is thus second order research i.e. it considers the process of researching research and the issue of multiple perspectives is an important feature. The justification of the use of a PAR framework is to be found in the forms of research that takes place 'with' people. The distinction between PAR methods and other qualitative methods is a philosophical one (Tolley and Bentley, 1996) between the roles played by the researcher and researched. The researcher "outsider" and participants "informants" are partners, sharing and learning together. The work is divided into two stages. The first is to determine the usefulness of the PAR framework in helping participants make assessments of their health needs, analyse their situation, develop strategies for solving problems themselves, and implement their own action plans. The second is to reflect on the research process itself, which allows for generation and testing of the methodology. This thesis has enhanced the contribution to the literature in this field. A development of the PAR framework emerged called the Health Analysis and Action Cycle (HAAC), via evaluating the PAR framework. The HAAC was found to be useful in allowing women's groups to assess their health needs, plan and take action to improve their health situation. For example, five of the six groups considered the importance of diarrhoea and developed strategies to reduce the incidence of diarrhoea in their communities. The sixth group's work centred on reducing the incidence of respiratory illness in their community. All the groups were able to assess, plan and implement projects to improve their environmental and hence health situation. The research stimulated collective action and empowerment of women participating in the research as it was the first time women had worked together to identify issues of diarrhoeal disease and respiratory illness and introduced preventative measures within their community. The HAAC approach, an additional innovation in this field, has relevance to the current theory and practice debate within the development sector. The model developed has possible implications for t~e concept of developing 'partnership' within the health and development sector and the development of emergent evaluation through developmental decision science.

Research consistently supports that some segments of society are at considerably higher risk for illness and death than the national average. While the existence and extent of poor health outcomes for these "vulnerable populations" are well documented, less research attempts to explain why such inequities persist and how they might be resolved. Thus, many vulnerable individuals fail to get adequate health care. How can health care delivery be improved to better serve those consumers most at risk of poor health? Addressing this issue requires an in-depth understanding of the unique health and social needs of vulnerable consumers and how these needs are being met (or not met) by the health care industry. Based on field research using a variety of methods, this study examined health care delivery to one at-risk population, women in a rural Appalachian coal mining community, with the ultimate goal of envisioning service design and distribution strategies that might better serve disadvantaged populations. Consistent with the change-oriented goal of this research, a feminist approach guided this study. Women's everyday experiences in managing their health needs were explored through an analysis of their health care stories. Health care providers were also interviewed in order to explore both sides of the service encounter dyad. The voices of the women and the providers reveal uneasy tensions in health care delivery and illuminate why the current system does not meet the actual health care needs of the women or their community. A variety of solutions are offered to improve health care delivery. / Ph. D.

Bakgrund: Lesbiska och bisexuella kvinnor har sämre fysisk och psykisk hälsa än heterosexuella kvinnor. De är en osynliggjord grupp inom vården. Inom kvinnosjukvården (gynekologi och obstetrik) finns en tradition av heterosexualitet i och med dess fokus på reproduktion. Tidigare studier har visat att lesbiska och bisexuella undviker gynekologisk vård på grund av dåligt bemötande. Obstetriken kommer framöver att få ta emot alltfler samkönade par. Det blir därför viktigt att förstå hur kvinnosjukvården upplevs av lesbiska och bisexuella kvinnor. Syftet är att belysa lesbiska och bisexuella kvinnors upplevelser av kvinnosjukvården. Metod: Litteraturöversikt av 13 forskningsstudier. Textanalys med beskrivande sammanställning av inkluderade studiers resultat. Teoretiska referensramar är vårdrelation och heteronormativitet. Resultat: Det finns heteronormativitet och homofobi inom kvinnosjukvården på både individuell och strukturell nivå. Brister i bemötandet handlade om att bli exkluderad, samt att mötas av fientlighet, omedvetenhet eller okunskap. Detta fick negativa konsekvenser för studiernas deltagare, och ledde till olika strategier för att hantera och förebygga negativa vårdsituationer. Positiva upplevelser av vården relaterades till medvetenhet och kunskap kring sexuell läggning i form av öppenhet och kommunikation, samt när vårdpersonal signalerade acceptans och positiva attityder. Små förändringar i bemötandet kunde göra stor skillnad i mötet. Diskussion: Förutsättningarna för en god vårdrelation försvåras av heteronormativitet, och vårdpersonal behöver bli medvetna om på vilka särskilda sätt som lesbiska och bisexuella kvinnor behöver bekräftelse i form av acceptans och inkluderande. Enskild vårdpersonal kan göra stor skillnad i upplevelsen av bemötandet, och på så sätt också vara del av en större förändring kring minskad heteronormativitet inom kvinnosjukvården. / Background. Lesbian and bisexual women have worse physical and mental health than heterosexual women. They are an invisible group in health care. Within women's health care, (gynecology and obstetrics) there is a tradition of heterosexuality due to the focus on reproduction. Previous studies have shown that lesbians and bisexuals avoid gynecological care due to the way they are received. Obstetrics will now be receiving more and more same-sex couples. That makes it important to understand how lesbian and bisexual women experience women’s health care. The aim is to highlight lesbian and bisexual women's experiences of women's health care. Method. Literature review of 13 research studies. Text analysis with descriptive summary of included studies' results. The theoretical frameworks are the nurse-patient relationship and heteronormativity. Results. Heteronormativity and homophobia exist within women's health care. Deficiencies in the the ways lesbians and bisexual women were received involved being excluded and encountering hostility, unawareness or ignorance. This led to the need for various strategies to manage and prevent adverse health situations. Positive experiences of care related to awareness and knowledge of sexual orientation in terms of openness and communication, as well as health professionals signaling acceptance and positive attitudes. Marginal changes in health professionals’ response could make a big difference for the lesbian and bisexual women. Discussions. The prospects of a good caring relationship is complicated by heteronormativity. Health professionals need to be aware of the specific ways in which lesbian and bisexual women may need confirmation. Individual health professionals can make a big difference to the way lesbian and bisexual women experience health care, and thereby also contribute to a wider improvement related to reduced heteronormativity in women’s healthcare.