Orientador: Luis Guillermo Bahamondes / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-26T02:46:23Z (GMT). No. of bitstreams: 1 Modesto_WaleskaOliveira_D.pdf: 13141867 bytes, checksum: 9829c0f68d8c82bcf73f017f9a8b6ab3 (MD5) Previous issue date: 2014 / Resumo: A diminuição da densidade mineral óssea (DMO), o ganho do peso e as alterações nos padrões de sangramento são frequentemente associados ao uso dos métodos de somente progestágeno. Aspectos não completamente elucidados quanto ao momento e tempo de ocorrência podem prejudicar a continuação e ocasionar descontinuação prematura ou induzir morbidades. Objetivos: Avaliar a DMO, ganho do peso e taxas de descontinuação por transtornos de sangramento dos métodos de somente progestágenos. Sujeitos e Métodos: realizaram-se quatro estudos sobre a influência do acetato de medroxiprogesterona de depósito (AMPD): A) sobre a DMO e a composição corporal (CC) de suas usuárias a partir dos 12 meses até os 23 anos de uso; B) sobre ganho de peso em usuárias do AMPD, do sistema liberador de levonorgestrel (SIU-LNG) e do dispositivo intra-uterino com cobre (DIU) até 10 anos de uso, C) sobre a influência do implante liberador de etonogestrel (ENG) na DMO e na CC até 24 meses de seguimento e D) avaliamos a influência de diferentes orientações em relação aos distúrbios do sangramento nas taxas de continuação das usuárias de SIU-LNG, implante liberador de ENG e DIU. Resultados: a DMO aos 12 meses de uso do AMPD foi menor na coluna lombar quando comparadas a usuárias de DIU e aos 10 anos de uso 29,8% das usuárias do AMPD apresentaram osteoporose comparado a 2,4% das usuárias de DIU. Na CC, observou-se que, aos 12 meses, ocorreu um aumento de 2Kg de massa gorda e 2% na porcentagem de massa gorda nas usuárias de AMPD, porém, a longo prazo, não houve diferença na quantidade de massa gorda quando comparadas à usuárias de DIU. O peso aumentou ao final do primeiro ano em 1,3Kg, 0,7Kg e 0,2Kg e, aos 10 anos, em 6,6Kg, 4,0Kg e 4,9Kg nas usuárias de AMPD, SIU-LNG e DIU, respectivamente. Nas usuárias do implante liberador de ENG ocorreu uma diminuição da DMO da coluna lombar aos 12 meses e um aumento de 2% a 2,7% da massa gorda aos 12 e 24 meses comparadas à usuárias de DIU. Mulheres que receberam orientações de rotina ou intensivas quanto ao padrão de sangramento esperado não mostraram diferenças significativas nas taxas de descontinuação do SIU-LNG, do implante liberador de ENG e do DIUT. Conclusões: O uso do AMPD ocasionou uma diminuição na DMO no primeiro ano de uso, essa diminuição foi progressiva e aumentou a prevalência de osteoporose em longo prazo. Usuárias do AMPD, SIU-LNG e DIU apresentaram ganho do peso aos 10 anos de uso, sendo maior em usuárias de AMPD. A massa gorda aumentou no primeiro ano de uso do AMPD, porém, não foi significante em longo prazo quando comparada à usuárias do DIU. Em usuárias do implante liberador de ENG foi encontrado um ganho do peso e da massa gorda aos 24 meses e uma diminuição da DMO após 12 meses. As estratégias de orientação de rotina e intensivas não apresentaram diferenças nas taxas de continuação das usuárias do implante liberador de ENG , SIU-LNG e DIU / Abstract: The decrease in bone mineral density (BMD), weight gain and changes in uterine bleeding patterns are often associated with the use of progestin-only methods. Aspects not still elucidated and the moment of occurrence could harm the continuation and provoke premature discontinuation or induce morbidities. Objectives: To evaluate BMD, weight gain and discontinuation rates for bleeding disturbances of progestin-only methods. Subjects and Methods: Four studies were conducted with depot medroxyprogesterone acetate (DMPA) users: A) regarding BMD and body composition (BC) from 12 months to 23 years of use; B) on weight gain among DMPA users, the levonorgestrel-releasing intrauterine system (LNG-IUS) and cooper-intrauterine device (IUD) up to 10 years of use; C) on the influence of the etonogestrel-releasing implant (ENG) upon BMD and BC up to 24 months of follow-up; and D) to evaluate the influence of two counseling strategies regarding to bleeding disorders in continuation rates of the users of the LNG-IUS, ENG-implant and IUD. Results: BMD after 12 months of DMPA use was lower at the lumbar spine compared to IUD users and 29.8% has osteoporosis among those women who had used DMPA for 10 years or more compared to 2.4% of IUD users. Regarding BC, at 12 months of use it was observed, an increase of 2 kg of fat mass and 2% in the percentage of fat mass in DMPA users; however, in the long-term use, there was no difference in the amount of fat mass compared to IUD users. The weight increased at the end of the first year was 1.3kg, 0.7kg and 0.2kg and, at 10 years, was 6.6kg, 4.0kg and 4.9kg among DMPA-, LNG-IUS- and IUD-users, respectively. Users of the ENG-implant showed a decrease in BMD at lumbar spine after 12 months of use and an increase of 2% to 2.7% of fat mass at 12 and 24 months when compared to IUD-users. Women who received routine or "intensive" counseling about the expected bleeding patterns showed no significant differences regarding the rates of discontinuation of LNG-IUS, ENG-implant and IUD. Conclusions: Users of DMPA showed a decrease in BMD at the end of the first year of use, the decrease was progressive and an increased prevalence of osteoporosis in the long-term use was observed. DMPA, LNG-IUS and IUD users showed weight gain after 10 years of use, higher in DMPA users. Fat mass increased in the first year of DMPA use; however, was not significant in the long-term when compared to IUD-users. In ENG-implant users it was found a weight gain and increase of fat mass at 24 months and a reduction in BMD after 12 months of use. The routine and "intensive" counseling showed no differences in rates of continuation in ENG-implant, LNG-IUS- and IUD-users / Doutorado / Fisiopatologia Ginecológica / Doutora em Ciências da Saúde

This study operationalized the five dimensions of health care access in the context of contraceptive service provision and used this framework to examine access to contraceptive care at health department (HD) (Title X funded) and federally qualified health center (FQHC) (primarily non-Title X funded) clinics in South Carolina and Alabama. A cross-sectional survey was conducted in 2017/18 that assessed clinic-level characteristics, policies, and practices related to contraceptive provision. Provision of different contraceptive methods was examined between clinic types. Survey items were mapped to the dimensions of access and internal consistency for each scale was tested with Cronbach's alpha. Scores of access were developed and differences by clinic type were evaluated with an independent t-test. The overall response rate was 68.3% and the sample included 235 clinics. HDs (96.9%) were significantly more likely to provide IUDs and/or Impants on-site than FQHCs (37.4%) (P < 0.0001). Scales with the highest consistency were Availability: Clinical Policy (24 items) (alpha = 0.892) and Acceptability (43 items) (alpha = 0.834). HDs had higher access scores than FQHCs for the Availability: Clinical Policy scale (0.58, 95% CL 0.55, 0.61) vs (0.29, 95% CL 0.25, 0.33) and Affordability: Administrative Policy scale (0.86, 95% CL 0.83, 0.90) vs (0.47, 95% CL 0.41, 0.53). FQHCs had higher access scores than HDs for Affordability: Insurance Policy (0.78, 95% CL 0.72, 0.84) vs (0.56, 95% CL 0.53, 0.59). These findings highlight strengths and gaps in contraceptive care access. Future studies must examine the impact of each dimension of access on clinic-level contraceptive utilization.

Bakgrund: Kvinnors behov av modern familjeplanering är inte tillgodosett. Samhällsekonomiska vinster finns att hämta om fler använder långverkande reversibla preventivmedel (LARC), i stället för mindre effektiva kortverkande metoder. Det finns ett behov av förbättrade arbetssätt för att kvinnor genom ett välinformerat beslut ska kunna välja effektiva preventivmedel. Syfte: Att undersöka om reproduktiv anamnes och sociodemografiska faktorer har en inverkan på valet av LARC vid strukturerad respektive sedvanlig preventivmedelsrådgivning, bland ungdomar och unga vuxna (18–24 år) på ungdomsmottagningar i Stockholmsregionen. Metod: Kvantitativ ansats. Klusterrandomiserad studie och substudie av LOWE-studien. Resultat: Planerad användning av LARC innan besöket (OR 45.78, 95% CI 23,54–89,02) och strukturerad preventivmedelsrådgivning (intervention) (OR 3,67, 95% CI 2,24–5,97) var de variabler som visade sig vara påverka valet av LARC. Slutsats: En trolig anledning till att sociodemografiska faktorer och reproduktiv anamnes inte påverkar valet av LARC i denna studie kan vara att preventivmedelsanvändning är ett mer komplext område. Den information som ges vid preventivmedelsrådgivning har en inverkan på majoriteten av alla patienter, men rådande samhällsnormer styr valet av preventivmedel tillsammans med paradigmskiften inom SRHR. Klinisk tillämpbarhet: Resultatet var av klinisk signifikans för vårdpersonal på ungdomsmottagningar och kan kliniskt tillämpas för en fördjupad kunskap kring bidragande faktorer för valet av LARC. / Background: Women’s need for modern family planning is not met. Socioeconomic benefits can be obtained if less-safe methods are replaced by long-acting reversible contraceptives (LARC). There is a need for improvement within the work to enable women to choose effective contraceptives by a well-informed decision. Aim: To investigate if reproductive history and socioeconomic factors have an impact on the choice of LARC under the influence of customary and structured contraceptive counselling, among adolescents and young adults (18-24) at youth clinics in Stockholm, Sweden. Method: Quantitative method. Cluster randomized controlled intervention study, and a substudy of LOWE. Result: Planned use of LARC before the visit (OR 45.78, 95% CI 23,54–89,02) and structured contraceptive counselling (intervention) (OR 3,67, 95% CI 2,24–5,97) was the variables that influenced the choice of LARC. Conclusion: A likely reason why sociodemographic factors and reproductive history did not influence the choice of LARC, could be that contraceptive use is a part of a more complex context. The information provided in contraceptive counselling has an influence on the majority of all patients, but current societal norms control the choice of contraception, as well as paradigm shifts within SRHR. External validity: The result was of clinical significance for staff at youth clinics and can be clinically applied for in-depth knowledge of influencing factors for the choice of LARC.

OBJECTIVES: This study examined implementation of telehealth for contraceptive care among health departments (HDs) in 2 Southern US states with centralized/largely centralized governance structures during the early phase of the COVID-19 pandemic. Sustaining access to contraceptive care for underserved communities during public health emergencies is critical. Identifying facilitators and barriers to adaptive service provision helps inform state-level decision making and has implications for public health policy and practice, particularly in states with centralized HD governance. DESIGN: Mixed-methods study including a survey of HD clinic administrators and key informant interviews with clinic- and system-level staff in 2 states conducted in 2020. SETTING: Health department clinics in 2 Southern US states. PARTICIPANTS: Clinic administrators (survey) and clinic- and system-level respondents (key informant interviews). Participation in the research was voluntary and de-identified. MAIN OUTCOME MEASURES: (1) Telehealth implementation for contraceptive care assessed by survey and measured by the percentage of clinics reporting telehealth service provision during the pandemic; and (2) facilitators and barriers to telehealth implementation for contraceptive care assessed by key informant interviews. For survey data, bivariate differences between the states in telehealth implementation for contraceptive care were assessed using χ2 and Fisher exact tests. Interview transcripts were coded, with emphasis on interrater reliability and consensus coding, and analyzed for emerging themes. RESULTS: A majority of HD clinics in both states (60% in state 1 and 81% in state 2) reported a decrease in contraceptive care patient volume during March-June 2020 compared with the average volume in 2019. More HD clinics in state 1 than in state 2 implemented telehealth for contraceptive services, including contraceptive counseling, initial and refill hormonal contraception, emergency contraception and sexually transmitted infection care, and reported facilitators of telehealth. Medicaid reimbursement was a predominant facilitator of telehealth, whereas lack of implementation policies and procedures and reduced staffing capacity were predominant barriers. Electronic infrastructure and technology also played a role. CONCLUSIONS: Implementation of telehealth for contraceptive services varied between state HD agencies in the early phase of the pandemic. Medicaid reimbursement policy and directives from HD agency leadership are key to telehealth service provision among HDs in centralized states.

Thesis (M.A. (Population and Reproductive Health Research))--Mahidol University, 2003.

Background: One in ten people in the U.S. are affected by a substance use disorder (SUD), roughly one third of whom are women. Rates of unintended pregnancy are higher in this population than in the general public. Little is understood about how women with SUD use prescription contraception and think about pregnancy. Methods: By analyzing Medicaid claims data and conducting qualitative interviews with women with SUD, this doctoral thesis seeks to: 1) compare any use of and consistent, continued coverage by prescription contraceptives between women with and without SUD; 2) determine the extent to which SUD is associated with pregnancy, abortion, and adverse feto-maternal outcomes in women who use prescription contraception; and 3) explore facilitators of and barriers to contraceptive utilization by women with SUD, using qualitative interviews. Results: Compared to women without SUD, women with SUD are less likely to use any prescription contraceptive, particularly long-acting reversible methods. Among women who do use long-acting methods, SUD is associated with less continued, consistent coverage by a prescription contraceptive. Among women who use contraception, SUD is also associated with increased odds of abortion. When interviewed, women with SUD report fatalistic attitudes towards pregnancy planning, and have difficulty conceptualizing how susceptibility to pregnancy may change over time. Women with SUD also report that pregnancy has substantial impact on their drug treatment prospects. Conclusions: This study is the first to examine contraceptive utilization by women with SUD who are enrolled in Medicaid or state-subsidized insurance. Our study may help to inform clinical practice and policy development to improve the reproductive health and wellbeing of women with SUD.