Introuction: The sub-Saharan Africa (SSA) region is making progress in its contraceptive policies that allow for the provision of long-acting reversible contraceptives (LARC). Despite this, the overall utilisation of contraception, especially LARC is low while the burden of unintended pregnancies remains high. Unintended pregnancies pose a significant threat to global public health with far-reaching consequences. There is a need to explore all the reasons for the low uptake of effective LARC methods. The objectives of this systematic review and meta-analysis, was therefore to determine the state of knowledge, attitudes, and perceptions of LARCs among healthcare workers (HCW) in sub-Saharan Africa. Methods: A systematic review and meta-analysis were conducted of published qualitative and quantitative studies. A search strategy was developed and applied to three major databases (PubMed, Ovid (Medline), and Scopus). Studies of both a qualitative and quantitative nature were included if they assessed either the knowledge, attitude, perception or a combination of the concepts among HCWs toward a LARC method. Data were extracted using a pre-determined data extraction form to conduct a qualitative synthesis using a thematic content analysis framework using ATLAS.ti version 8. In addition to this, data was specifically extracted relating to 11 pre-determined questions to conduct proportion meta-analyses using Stata version 15. Heterogeneity was further explored using the I2-statistic and publication bias using funnel plots and Egger’s tests. Results: A total of 3616 records were screened, of which 3510 were excluded. From 106 full-text articles assessed for eligibility, 50 were included for qualitative synthesis and 21 included in the meta-analysis. From the studies, a total of 12 356 participants were included in the analysis. From the meta-analysis, the overall proportion of HCWs with training in family planning was 62% (95% CI: 48%, 76%) while 60% (95% CI: 41%, 80%) reported providing family planning counselling to their clients. Forty-one percent (95% CI: 20%, 61%) of HCWs had received IUCD insertion training with 63% (95% CI: 44%, 81%) expressing a desire for additional training. Only 27% of HCWs (95% CI: 18%, 36%) deemed IUCD appropriate for HIV-infected women. Moreover, restrictions for IUCD and injectables based on a minimum age were imposed by 56% (95% CI: 33%, 78%) and 60% (95% 41 CI: 36%, 84%) of HCWs, respectively. Lastly, minimum parity restrictions were also observed among 29% (95% CI: 9%, 50%) of HCWs for IUCDs and 36% (95% CI: 16%, 43 56%) for injectable contraceptives. Conclusion: The study revealed that there is a gap in knowledge of HCWs regarding family planning counselling and LARC provision. In addition to this, the results indicate that unnecessary provider-imposed restrictions may hinder the uptake of LARC methods by women in sub-Saharan Africa. With the deadline for the Family Planning 2020 initiative and the 2030 SDGs quickly approaching, there is a need to address these issues. / Dissertation (MSc)--University of Pretoria, 2020. / School of Health Systems and Public Health (SHSPH) / MSc (Epidemiology) / Unrestricted

Unintended pregnancy leads to many public health consequences like lower educational attainment and diminished career opportunities, with higher rates of unintended pregnancies occurring in lower income communities and among women with drug addiction. Beyond preventing unintended pregnancies, effective contraception helps prevent poor birth spacing, thereby reducing the risk of both premature and low-weight births and maternal mortality and morbidity during the peripartum period. Long acting reversible contraceptives (LARCs), such as intrauterine devices (IUDs) and implants, are considered the birth control of choice for women of reproductive potential as they possess a number of advantages: cost-effectiveness, minimal maintenance for 3 to 10 years, reversibility, and high efficacy and continuation rates. Despite these benefits, LARCs have been widely underused in rural communities as a result of many factors including hospital and gynecology department closures, workforce shortages, provider knowledge, and access to care challenges that arise from complex social determinants of health specific to rural US communities. We therefore investigated the knowledge and current practice of clinical providers regarding LARCs counseling and provision in Hawkins County of Northeast Tennessee. Hawkins County is a primarily rural county with clinics serving a large lower income population with a high prevalence of substance use, therefore making it at risk for higher rates of unintended pregnancies. An online survey was sent to all consenting medical providers (NPs, PAs, and physicians) (n=7) to collect information on their practices related to contraception, including LARCs. Following completion of online surveys, semi-structured interviews (n=2) were planned to qualitatively explore providers’ perspectives. Quantitative analysis of survey data and thematic analysis of interviews were conducted. Analysis of survey data shows that though non-OB/GYN primary care providers reported on being somewhat comfortable to comfortable in their ability to counsel patients on LARCs, they reported low levels of actually counseling on LARCs, compared with oral contraception. Furthermore, the survey data also shows low levels of LARC insertion/removal among non-OB/GYN primary care providers, with most noting preference to refer patients to a private OB/GYN provider within the community or the health department. Additionally, non-OB/GYN primary care providers reported little to no interest in including insertion/removal of LARCs within their scope of practice, citing clinic supply, no time for procedures, and low patient desire as reasons. All providers reported believing that there are little to no barriers to obtaining LARCs by patients within Hawkins County.The semi-structured interviews, including one with the county’s main OB/GYN provider, indicated that though there is access to LARCs within Hawkins County, there may still be multiple barriers including possible poor quality of counseling on LARCs by non-OB/GYN primary care providers and preference for counseling specific populations on LARCs rather than all patients of reproductive potential, both of which may contribute to low patient desire for LARCs. This work is a useful starting place for increasing utilization of LARCs within Hawkins County. By exploring current knowledge and practices of primary care providers, we can better address potential systematic barriers to improve access to and utilization of LARCs in rural communities.

Research is presented on the crystallization and melting behavior of an aromatic semi crystalline polyimide known as LaRC CPI - 2 (Langley Research Center Crystalline rolyimide - second generation). This aromatic polyimide, a structural variant of the well known LaRC CPI, is synthesized froml 1,4-bis( 4-aminophenoxy-4' -benzoyl)benzene (1,4-BABB) and 4,4' -oxydiphthalic dianhydride (ODPA). The multiple melting behavior at ca. 334°C and 364°C, characteristic of this polymer, is analyzed and explained. Transmission electron microscopy (TEM), wide angle X-ray diffraction (W AXD), and small angle X-ray scattering (SAXS) studies, in conjunction with differential scanning calorimetry (DSC) analysis, show that the high melting transition results from the melting of lamellae which were melt recrystallized during heating in a DSC. The effects of synthesis and process variables upon the crystallization and melting properties of this polyimide were also studied. The DSC response of LaRC CPI - 2 films and powders of varying molecular weight are compared and contrasted. Powders generally melt at a higher temperature than films of the same molecular weight. The glass transition temperature, T g' of both the powders and films are found to be dependent upon molecular weight. An interpolated value of T g for the infinite molecular weight LaRC CPI - 2 is ca. 234°e. In a study of the development of crystallinity in films during standard thermal imidization, crystallinity was found to initiate off the glass surface very early in the process leaving an amorphous layer at the air surface after the full thermal treatment. LaRC CPI - 2 powder 'types' synthesized in different solvents, dimethylacetamide (DMAc) and m-cresol present with dramatically different melting, melt stability and crystallization properties. Though the chemical architecture and crystal lattice structure are the same, the powders synthesized in DMAc display dual melting transitions at ca. 334°C and 364°C, while the powders from m-cresol melt singularly at ca. 409°C. Rheological analysis, along with annealing data, revealed a higher temperature melt stability in the powders from m-cresol. It is postulated that the differences in the properties of the two powders are the result of differing initial molecular weights and a suppression of a cross-linking ketimine reaction in the polymer produced in m-cresol. / Ph. D.

In the United Kingdom (UK) there is easy access to a wide range of contraceptive methods, available at no cost. In addition, oral emergency contraception (EC) (1.5 mg levonorgestrel) is now widely available from the community pharmacy. In spite of this, unintended pregnancy is common. In 2014 in England and Wales, 184,571 induced abortions were performed, and in Scotland, the corresponding figure was 11,475. Long acting reversible methods such as contraceptive implants and intrauterine contraception, are amongst the most effective methods available and National Institute for Health and Care Excellence (NICE) recommends that increased uptake can lead to fewer unintended pregnancies. However, uptake of long acting reversible contraceptive (LARC) methods remains low. The majority of women who require to use EC do so following unprotected sex or an accident with a condom. Increasingly women in Great Britain prefer to attend a pharmacy for EC rather than a sexual and reproductive health (SRH) service or general practitioner (GP). Starting an effective on-going method of contraception after EC use is clearly important if women are to avoid unintended pregnancy. Community pharmacists in the UK and most other high income countries are usually unable to provide any on-going contraception except condoms. So we have created a situation where EC is provided almost solely from settings where other more effective methods of contraception cannot be immediately provided. Novel strategies are therefore required to facilitate both uptake and continuation of the most effective methods of contraception, in order to prevent unintended pregnancy for more women. This thesis presents a mixture of biomedical, clinical and health services research to evaluate a series of strategies aimed at improving uptake of the most effective methods of contraception. Two studies investigated patient knowledge and information provision relating to contraceptive methods. The first sought to determine if women held misconceptions about intrauterine methods of contraception, and revealed that although myths persist in a small number of women, a lack of knowledge about these methods was also evident. The second study aimed to determine if the use of a digital video disc (DVD) to provide contraceptive information was acceptable and informative to women, and identified that it is, and could possibly enhance patient consultations. Studies three, four and five investigated strategies aimed at increasing the uptake of effective on-going contraception, following emergency contraception provided from a community pharmacy, and patient and health care provider attitudes to such approaches. They showed that simple interventions such as supplying one month of a progestogen only pill (POP), or offering rapid access to a family planning clinic (FPC), hold promise as strategies to increase the uptake of effective contraception after EC and that both women and clinicians were positive about such measures. Additionally, the problems encountered in conducting these studies provided valuable feedback to inform further development of research methods in the community pharmacy setting, and larger scale studies of such interventions. Community SRH services may be well placed to deliver more abortion care in the UK, and consequently this may result in greater uptake of contraception post abortion. Study six aimed to determine the views of health professionals working in SRH regarding their attitudes towards providing more abortion services and also the views of staff within one community SRH centre in Scotland where a service providing early medical abortion was due to commence. It showed there is clear support amongst health professionals in community SRH in the UK towards greater participation in provision of abortion care services.

Sumário: O DIU TCu380A é um método contraceptivo de alta eficácia e taxa de continuidade. O ACOG recomenda que o mesmo seja oferecido como primeira linha de contracepção para adolescentes independente da paridade. A falta de conhecimento e informação apropriada pode ser um fator decisivo para a nãoescolha do método. Objetivos: avaliar o grau de conhecimento sobre o DIU e identificar os principais motivos para sua não-escolha como contraceptivo por adolescentes entre 13 e 19 anos. Materiais e Métodos: Estudo transversal, prospectivo, onde o fator em estudo é o conhecimento sobre DIU e o desfecho é prevalência da opção pelo uso DIU (reposta SIM a pergunta " usaria DIU "). A amostra foi de 38 pacientes que consultam nos ambulatórios ou são puérperas internadas na maternidade do HCPA. O instrumento foi um questionário para auto-preenchimento. Análise de dados foi realizada por SPPS 18 e InfoStat. Resultados: A média de idade das entrevistadas foi de 16,05 anos (DP 1,33). Para analisar as perguntas verdadeiro/falso sobre assertivas acerca do DIU, criou-se a variável identificada como conhecimento correto, que correspondia ao acerto das 7 questões Não se encontrou associação entre conhecimento correto e possibilidade de uso de DIU (variável "usaria DIU") (Teste Exato de Fischer, p = 0,4, poder de 99,5%). Nas análises individuais para cada uma das assertivas de verdadeiro ou falso e a variável “usaria DIU", apenas a assertiva "A pílula é um método mais seguro que o DIU" emergiu como marginalmente significativa (Yates, bi-caudal 0,08, poder 60%). Observou-se uma associação entre maior escolaridade e conhecimento correto sobre o DIU (p=0,03, teste exato de Fischer). O principal motivo de recusa para uso encontrado foi informação insuficiente (26,3%) e medo da colocação (10,5%). Conclusões: O conhecimento correto de que a pílula não é um método mais seguro que o DIU significativamente influencia o uso do DIU no futuro. O fato das demais assertivas não determinarem maior escolha pelo DIU demonstra que o fato de desconhecerem que estarão mais protegidas com o uso de um LARC limita o uso do DIU. É fundamental informar as equipes de saúde que o DIU é um método mais efetivo e que não existe nenhum impeditivo para seu uso em adolescentes. / Background: The TCu380A IUD is a contraceptive method with high efficacy and continuity. The ACOG recommends that it should be offered as the first line of contraception for adolescents, despite parity. Lack of knowledge and appropriate information about the method can be a decisive factor for nonchoice. Objectives: to evaluate the degree of knowledge about the IUD and to identify the main reasons for not choosing the contraceptive method for adolescents between 13 and 19 years of age. Material and Methods: A cross-sectional, prospective study which the objective was to evaluate the knowledge about IUDs and the outcome was the prevalence of IUD possible use. The sample consisted of 38 patients who were attended at Gynecology and Obstetrics clinic or were hospitalized at the maternity (puerperium period) of the hospital. The instrument was a self-completion questionnaire. Data analysis was performed by SPPS 18 and InfoStat. Results: The average age of the interviewers was 16.05 years (SD 1.33). To analyze the true / false assertive questions about the IUD, we created the variable identified as correct knowledge, which corresponded to the correctness of the 7 questions There was no association between correct knowledge and the possibility of using IUDs. (Fischer's Exact Test, p = 0.4, 99.5% power). In the individual analyzes for each of the assertions of true or false and the variable would use IUDs, only the assertive " The pill is a safer method than the IUD " emerged as marginallly significant (Yates, two-tailed p = 0.08, power 60%). There was an association between higher education and correct knowledge about the IUD (p = 0.03, Fischer's exact test). The main reason for the refusal to use IUD was insufficient information (26.3%) and fear of insertion (10.5%). Conclusions: The correct knowledge that the pill is not a safer method than the IUD significantly influences the possibilty of IUD use in the future. The fact that the other assertions do not determine a greater choice for the IUD demonstrates that lack of knowledge that they would be more protected with the use of a LARC limits the IUD use. It is critical to inform health teams that the IUD is a more effective method and that there is no impediment to expand its use in adolescents and reduce the rate of pregnancy in adolescence.

Reducing the percentage of unwanted pregnancies has been one of the top objectives of the national health promotion "Healthy People" since the early 1980s. As the increase of unwanted pregnancies continues, research is necessary to uncover factors that influence the decisions women make about their contraceptive methods. The current study examines the topics and the sources of memorable messages regarding LARCs. To address the research questions, this study will analyze interviews conducted with young women about memorable messages regarding LARC methods. This study is a formative research of memorable messages in the context of contraceptive methods, specifically long-acting reversible contraceptives (LARCs). This study gives insight into characteristics to better target young women when promoting contraceptive methods, especially LARCs. Debunking myths and misconceptions about LARCs and improve overall health literacy about these methods among young women and their mothers should be a top priority.

Sumário: O DIU TCu380A é um método contraceptivo de alta eficácia e taxa de continuidade. O ACOG recomenda que o mesmo seja oferecido como primeira linha de contracepção para adolescentes independente da paridade. A falta de conhecimento e informação apropriada pode ser um fator decisivo para a nãoescolha do método. Objetivos: avaliar o grau de conhecimento sobre o DIU e identificar os principais motivos para sua não-escolha como contraceptivo por adolescentes entre 13 e 19 anos. Materiais e Métodos: Estudo transversal, prospectivo, onde o fator em estudo é o conhecimento sobre DIU e o desfecho é prevalência da opção pelo uso DIU (reposta SIM a pergunta " usaria DIU "). A amostra foi de 38 pacientes que consultam nos ambulatórios ou são puérperas internadas na maternidade do HCPA. O instrumento foi um questionário para auto-preenchimento. Análise de dados foi realizada por SPPS 18 e InfoStat. Resultados: A média de idade das entrevistadas foi de 16,05 anos (DP 1,33). Para analisar as perguntas verdadeiro/falso sobre assertivas acerca do DIU, criou-se a variável identificada como conhecimento correto, que correspondia ao acerto das 7 questões Não se encontrou associação entre conhecimento correto e possibilidade de uso de DIU (variável "usaria DIU") (Teste Exato de Fischer, p = 0,4, poder de 99,5%). Nas análises individuais para cada uma das assertivas de verdadeiro ou falso e a variável “usaria DIU", apenas a assertiva "A pílula é um método mais seguro que o DIU" emergiu como marginalmente significativa (Yates, bi-caudal 0,08, poder 60%). Observou-se uma associação entre maior escolaridade e conhecimento correto sobre o DIU (p=0,03, teste exato de Fischer). O principal motivo de recusa para uso encontrado foi informação insuficiente (26,3%) e medo da colocação (10,5%). Conclusões: O conhecimento correto de que a pílula não é um método mais seguro que o DIU significativamente influencia o uso do DIU no futuro. O fato das demais assertivas não determinarem maior escolha pelo DIU demonstra que o fato de desconhecerem que estarão mais protegidas com o uso de um LARC limita o uso do DIU. É fundamental informar as equipes de saúde que o DIU é um método mais efetivo e que não existe nenhum impeditivo para seu uso em adolescentes. / Background: The TCu380A IUD is a contraceptive method with high efficacy and continuity. The ACOG recommends that it should be offered as the first line of contraception for adolescents, despite parity. Lack of knowledge and appropriate information about the method can be a decisive factor for nonchoice. Objectives: to evaluate the degree of knowledge about the IUD and to identify the main reasons for not choosing the contraceptive method for adolescents between 13 and 19 years of age. Material and Methods: A cross-sectional, prospective study which the objective was to evaluate the knowledge about IUDs and the outcome was the prevalence of IUD possible use. The sample consisted of 38 patients who were attended at Gynecology and Obstetrics clinic or were hospitalized at the maternity (puerperium period) of the hospital. The instrument was a self-completion questionnaire. Data analysis was performed by SPPS 18 and InfoStat. Results: The average age of the interviewers was 16.05 years (SD 1.33). To analyze the true / false assertive questions about the IUD, we created the variable identified as correct knowledge, which corresponded to the correctness of the 7 questions There was no association between correct knowledge and the possibility of using IUDs. (Fischer's Exact Test, p = 0.4, 99.5% power). In the individual analyzes for each of the assertions of true or false and the variable would use IUDs, only the assertive " The pill is a safer method than the IUD " emerged as marginallly significant (Yates, two-tailed p = 0.08, power 60%). There was an association between higher education and correct knowledge about the IUD (p = 0.03, Fischer's exact test). The main reason for the refusal to use IUD was insufficient information (26.3%) and fear of insertion (10.5%). Conclusions: The correct knowledge that the pill is not a safer method than the IUD significantly influences the possibilty of IUD use in the future. The fact that the other assertions do not determine a greater choice for the IUD demonstrates that lack of knowledge that they would be more protected with the use of a LARC limits the IUD use. It is critical to inform health teams that the IUD is a more effective method and that there is no impediment to expand its use in adolescents and reduce the rate of pregnancy in adolescence.

Sumário: O DIU TCu380A é um método contraceptivo de alta eficácia e taxa de continuidade. O ACOG recomenda que o mesmo seja oferecido como primeira linha de contracepção para adolescentes independente da paridade. A falta de conhecimento e informação apropriada pode ser um fator decisivo para a nãoescolha do método. Objetivos: avaliar o grau de conhecimento sobre o DIU e identificar os principais motivos para sua não-escolha como contraceptivo por adolescentes entre 13 e 19 anos. Materiais e Métodos: Estudo transversal, prospectivo, onde o fator em estudo é o conhecimento sobre DIU e o desfecho é prevalência da opção pelo uso DIU (reposta SIM a pergunta " usaria DIU "). A amostra foi de 38 pacientes que consultam nos ambulatórios ou são puérperas internadas na maternidade do HCPA. O instrumento foi um questionário para auto-preenchimento. Análise de dados foi realizada por SPPS 18 e InfoStat. Resultados: A média de idade das entrevistadas foi de 16,05 anos (DP 1,33). Para analisar as perguntas verdadeiro/falso sobre assertivas acerca do DIU, criou-se a variável identificada como conhecimento correto, que correspondia ao acerto das 7 questões Não se encontrou associação entre conhecimento correto e possibilidade de uso de DIU (variável "usaria DIU") (Teste Exato de Fischer, p = 0,4, poder de 99,5%). Nas análises individuais para cada uma das assertivas de verdadeiro ou falso e a variável “usaria DIU", apenas a assertiva "A pílula é um método mais seguro que o DIU" emergiu como marginalmente significativa (Yates, bi-caudal 0,08, poder 60%). Observou-se uma associação entre maior escolaridade e conhecimento correto sobre o DIU (p=0,03, teste exato de Fischer). O principal motivo de recusa para uso encontrado foi informação insuficiente (26,3%) e medo da colocação (10,5%). Conclusões: O conhecimento correto de que a pílula não é um método mais seguro que o DIU significativamente influencia o uso do DIU no futuro. O fato das demais assertivas não determinarem maior escolha pelo DIU demonstra que o fato de desconhecerem que estarão mais protegidas com o uso de um LARC limita o uso do DIU. É fundamental informar as equipes de saúde que o DIU é um método mais efetivo e que não existe nenhum impeditivo para seu uso em adolescentes. / Background: The TCu380A IUD is a contraceptive method with high efficacy and continuity. The ACOG recommends that it should be offered as the first line of contraception for adolescents, despite parity. Lack of knowledge and appropriate information about the method can be a decisive factor for nonchoice. Objectives: to evaluate the degree of knowledge about the IUD and to identify the main reasons for not choosing the contraceptive method for adolescents between 13 and 19 years of age. Material and Methods: A cross-sectional, prospective study which the objective was to evaluate the knowledge about IUDs and the outcome was the prevalence of IUD possible use. The sample consisted of 38 patients who were attended at Gynecology and Obstetrics clinic or were hospitalized at the maternity (puerperium period) of the hospital. The instrument was a self-completion questionnaire. Data analysis was performed by SPPS 18 and InfoStat. Results: The average age of the interviewers was 16.05 years (SD 1.33). To analyze the true / false assertive questions about the IUD, we created the variable identified as correct knowledge, which corresponded to the correctness of the 7 questions There was no association between correct knowledge and the possibility of using IUDs. (Fischer's Exact Test, p = 0.4, 99.5% power). In the individual analyzes for each of the assertions of true or false and the variable would use IUDs, only the assertive " The pill is a safer method than the IUD " emerged as marginallly significant (Yates, two-tailed p = 0.08, power 60%). There was an association between higher education and correct knowledge about the IUD (p = 0.03, Fischer's exact test). The main reason for the refusal to use IUD was insufficient information (26.3%) and fear of insertion (10.5%). Conclusions: The correct knowledge that the pill is not a safer method than the IUD significantly influences the possibilty of IUD use in the future. The fact that the other assertions do not determine a greater choice for the IUD demonstrates that lack of knowledge that they would be more protected with the use of a LARC limits the IUD use. It is critical to inform health teams that the IUD is a more effective method and that there is no impediment to expand its use in adolescents and reduce the rate of pregnancy in adolescence.

This bachelor thesis has studied the relationship between politics and birth control for men. By doing a qualitative content analysis on 18 motions and propositions and carrying out two interviews the two following research questions have been answered: How is the relationship between politics and birth control for men? and How is the relationship between politics and innovations in LARC for men? First of all the results show that the relationship consists of a demand for birth control for men from politicians. However, there is a different point of view regarding birth control for men and politicians than what political institutions such as the Swedish riksdag and the Swedish government believe. The motions and the interviews that I studied showed that birth control for men is about prioritising men’s sexual health and right now it is not prioritised. It also indicates that the relationship between politics and innovations in LARC for men is scarce, not many politicians talk about the need for LARCs both in a general sense but also in a specific sense such as vasectomy. Also different committees do not talk at all about LARCs. The results from the interviews showed that both politicians and scientists feel that birth control for men should be a priority and more should be done in order for change to be made. Lastly, more research needs to be done in order to be able to generalize the results to a bigger population.

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