Background: Despite a wide range of contraceptive options available in the United Kingdom, the unplanned pregnancy rate remains high. Contraceptive services are currently delivered by general practitioners, sexual health clinics and pharmacies, but there may be scope to expand the places that these are offered, and increase the options available within each service. Doing so could increase the uptake of contraceptive methods, particularly the most effective methods, and therefore reduce the unplanned pregnancy rate. Aim and objectives: Research in this thesis aimed to investigate novel delivery models of contraception. The research had two main areas of focus. Firstly the capacity of the pharmacy to deliver regular contraception was examined, in the context of existing literature, and then through a pilot study. After that the expansion of contraception care to maternity services was investigated, first in the literature and then using an observational study. Methods: In undertaking this thesis I used a variety of methods. Two patient surveys were employed to investigate patients’ perspectives on proposed novel methods of contraceptive delivery. A pilot study investigated the feasibility and acceptability of delivery of the contraceptive injection at the pharmacy. Quantitative results about the numbers of injections given were collected, as were patient questionnaires. Qualitative one-to-one interviews were conducted with participating pharmacists, these were recorded, transcribed and analysed. An observational study was also undertaken to assess routine delivery of insertion of intra-uterine contraception at the time of caesarean section. Patients were seen at six weeks following insertion, and contacted by telephone at three, six and 12 months about satisfaction and continuation of the method. Results: 220 women completed a questionnaire about attending the community pharmacy to receive a contraception injection. 33% of current non-users indicated that they would consider using this method if it was available at the pharmacy. 50 established users of the contraceptive injection participated in a pilot project receiving up to three injections from the community pharmacy. Only 48 injections of a possible 150 were delivered at the community pharmacy. Only 7 participants received all three injections at the pharmacy, and participants reported mixed experiences accessing the pharmacy. The practical obstacles around pharmacy engagement and the challenges of retaining participants were significant, and more research is necessary before proceeding with a randomised controlled trial. 250 women on a postnatal ward completed questionnaires about their pregnancy intentions. 96.7% were not planning a baby in the next year, but only 23.6% were planning on using the most effective methods of contraception. One in three respondents described themselves as likely to use either an implant or intra-uterine contraception if it could be inserted before they left the hospital. In an observational study, 120/877 women opted to have intra-uterine contraception inserted at the time of caesarean section. Continuation rates at 12 months were 84.8% of those contacted, and 92.6% were either ‘very’ or ‘fairly’ happy with their contraception. Conclusion: Although patients are receptive to contraception being delivered using novel service models, alternatives to current practice need careful investigation. Contraceptive injections at the community pharmacy are not necessarily more convenient for patients, and therefore may not increase uptake of this method. However, offering intrauterine contraception to patients at the time of caesarean section is highly acceptable to patients, and results in a substantial majority continuing this highly effective method. Robust and careful research using a range of methods can help to identify which innovative approaches to contraceptive delivery offer the most promise.

The objective of this research project is to determine, by means of an exploratory study, which factors in Regional Offices of the National Department of Public Works, influence the success of unplanned maintenance on property. The report has been divided into five chapters. Chapter one consists mainly of the introduction, statement of the problem, hypothesis and delimitations and background of this report. Chapter two contains the literature review. Chapter three contains the research methodology and a practical investigation. Chapter four presents the collection and analysis of data. In the last chapter of this report, chapter five, the summary, conclusions and recommendations are presented. / Thesis (MSc (Project Management))--University of Pretoria, 2004. / Construction Economics / unrestricted

Unplanned adolescent pregnancy is one of the challenges that South Africa has been dealing with for years. This challenge is further complicated by the soaring HIV/AIDS infection rates, particularly among young people. The study aimed to explore adolescents’ understanding and meaning of the continuing unplanned pregnancies among adolescents in view of high HIV/AIDS prevalence. Thirteen male and female adolescents aged between 14 years and 25 years made up the participants. Three of them are mothers, four are university students and eight are high school learners. The study was undertaken in a high school, a university, and a clinic in Soweto. Unstructured interviews were used and the topics included adolescents’ knowledge on HIV/AIDS, their thoughts on the continued high levels of unplanned adolescent pregnancies, and their perceptions of the consequences thereof. The participants viewed unplanned adolescent pregnancies as a continuing problem within their communities. Unplanned adolescent pregnancy was described as a product of several factors within and beyond the control of young people. Some of the identified contributory factors are impulsivity, perceived invulnerability, financial dependence, and underdeveloped planning on the part of adolescents. Fertility is highly regarded in certain societies. The participants have a good knowledge of HIV/AIDS, which they receive from several sources such as schools, media, etc. However, HIV/AIDS is not always a deterrent to unprotected sex and the subsequent unplanned pregnancies among adolescents. Most participants do not see the relationship between unplanned pregnancies and HIV/AIDS. Instead, some young people see the prevention of pregnancy as more important than the preservation of life through the prevention of HIV infection. Knowledge about HIV/AIDS does not translate into behaviour change. A significant underestimation of personal risk to HIV/AIDS was observed. The fatality and reality of HIV/AIDS is often ignored and denied.

Purpose: The purpose of this study was to investigate associations between postoperative delirium (POD) and unplanned perioperative hypothermia (UPH) among adults undergoing noncardiac surgery. Design: A retrospective, exploratory design was used. Methods: A retrospective, exploratory study was conducted using electronic medical record data abstracted from a purposive convenience sample of adult patients undergoing noncardiac surgery from January 2014 to June 2017. Findings: The analyzed data set included 22,548 surgeries, of which 9% experienced POD. Logistic regression indicated that American Society of Anesthesiologists (ASA) class was the strongest predictor of POD (χ2 = 1,207.11, df = 4, inclusive of all ASA class terms). A significant relationship between UPH and POD (χ2 = 54.94, df = 4, inclusive of all UPH terms) and a complex relationship among UPH, patient age, ASA class, and POD were also found. Conclusions: Results support a relationship between UPH and POD. Notably, there is also a complex relationship in the noncardiac surgery population among UPH, age, ASA class, and POD. Preliminary understanding of this relationship is based on the pathophysiological response to surgical stress. Further research is indicated.

Background: Prevention of unplanned pregnancy is a crucial aspect of preventing mother-to-child HIV transmission (PMTCT). However, we have little understanding of how HIV status and antiretroviral therapy (ART) may influence pregnancy planning. There are few data on pregnancy planning in HIV-infected South African women, and no comparative data with HIV-uninfected women. Methods: We conducted a cross-sectional study of 2105 pregnant women (1512 HIV-infected; 593 HIV-uninfected) ages 18-44 making their first antenatal clinic visit at a primary-level health care facility in Gugulethu, Cape Town. All women completed structured questionnaires including the London Measure of Unplanned Pregnancy (LMUP), a 6-item scale that categorizes pregnancies into planned, ambivalent and unplanned. Analyses examined LMUP results across 4 groups of participants: HIV-infected established on ART; known HIV-infected but not currently on ART; newly diagnosed HIV-infected; and HIV-uninfected. Results: Overall, the mean age was 29 years (SD: 5.63), 43% of women were married or cohabiting and 20% were nulliparous. The LMUP performed well across all groups (Cronbach's α=0.84). Levels of unplanned pregnancy were higher in HIV-infected versus HIV-uninfected women (50% vs. 33%, p<0.001); and highest in women not on ART. Overall, 69% of women reported contraceptive use in the year before pregnancy; this was strongly associated with unplanned pregnancy (p<0.001). Compared to HIV-uninfected women, HIV-infected women had significantly higher odds of unplanned pregnancy, even after adjusting for age, parity and cohabiting status. The odds were greatest among women newly-diagnosed with HIV and previously diagnosed but not on ART (OR: 1.43; 95% CI: 1.05-1.94 and OR: 1.56; 95% CI: 1.13-2.15, respectively). Increased parity and age <24 years were also associated with unplanned pregnancy (OR 1.83; 95% CI: 1.24-2.74 and OR 1.42; 95% CI: 1.25- 1.60 respectively). Conclusions: These data indicate high levels of unplanned pregnancy in a high HIV prevalence setting, highlighting missed opportunities for family planning and counselling services for HIVpositive women. Possible explanations for the high level of unplanned pregnancy observed include contraceptive failure and/or misuse thereof. Therefore, women living with HIV require additional support to avoid unplanned, particularly those who are younger and have one or more children.

Unplanned hospital admissions (UHA) in older adult populations are a recurring problem in older adults with cancer. Older adults comprise approximately 60% of cancer diagnoses and receive the majority of cancer treatment. However, little is known about why older adults under treatment for cancer experience a high number of unplanned hospital admissions. A review of the literature provided few study findings and a gap in the current knowledge was identified regarding the factors associated with unplanned hospital admissions in older adults under treatment for cancer. A conceptual framework based on the literature and this researcher's clinical experienced guided this study. The purpose of this study was to explore the factors related to unplanned hospital admissions and determine if one or more factors are predictive of unplanned hospital admissions of older adults with cancer. A convenience sample of 129 dyads of older adults with cancer and their family caregivers were approached and enrolled in the adult oncology outpatient infusion centers and inpatient units within a community cancer center in central Florida. Patient demographic and clinical data were obtained through a retrospective medical record review. Family caregiver demographic and side effect knowledge data was collected prospectively during interviews with family caregivers using a newly developed tool, Nurse Assessment of Family Caregiver Knowledge and Action Tool (NAFCKAT). The NAFCKAT contains 11 items to determine baseline knowledge about side effects and plan for managing side effects. A fever subsection consists of 4 knowledge and 2 action questions and a dehydration subsection consists of 2 knowledge and 2 action questions. Preliminary research was conducted to determine reliability and validity of the NAFCKAT. Excellent inter-reliability was found for the tool and preliminary support for validity was determined for the fever subscale. Descriptive statistics and logistic regression analyses were used to evaluate data collected from patient medical records and NAFCKAT scores. Study findings revealed that unplanned hospital admissions were more likely to occur when older adults had the presence of impaired function prior to treatment initiation and/or experienced side effects of infection /fever and vomiting/diarrhea during treatment. The presence of impaired function and family caregiver support (knowledge and availability) did not moderate the relationship between side effects and unplanned hospital admissions. Findings suggest that the presence of impaired function and side effects of infection and fever, and vomiting and diarrhea, predict unplanned hospital admissions in older adults during the active cancer treatment phase. Nurses should advocate for and conduct targeted assessments to identify the presence of functional impairments prior to cancer treatment initiation. In addition, nurses should actively monitor for the presence of cancer treatment-related side effects during the treatment phase of the cancer trajectory. Information gained from these assessments will assist nurses to provide practical and tailored strategies to support older adults and their family caregivers during cancer treatment and reduce the risk for unplanned hospital admissions.

Few studies explore the phenomenon of unintended pregnancy among women living with the Human Immunodeficiency Virus (HIV). To decrease mother-to-child transmission and transmission to a sexual partner, contraceptive methods, cultural beliefs, in addition to protocols pertaining to preconception, pregnancy, labor, delivery and the postpartum period among persons living with HIV must be considered. Half of the pregnancies that occur among HIV-positive women are unintended and requires monitoring and additional prenatal care to reduce adverse health outcomes. This qualitative study sought to increase knowledge of the meaning and understanding of unintended pregnancy among a sample of twelve urban HIV-seropositive African American women. Women shared their experiences related to pregnancy, risk and living with HIV. The majority of participants reported they experienced an unintended pregnancy, discussed lapses in contraception use, knowledge of pregnancy and antiretrovirals, vertical transmission of the virus, sexual risk, and differences in adherence to antiretrovirals during and after pregnancy. Guided by grounded theory the major themes that emerged were used to develop a model that explained unintended pregnancy among the participants. The major themes included resilience, disclosure, and an instinct to protect. Additionally, culture, stigma, social support, contraception, and partner safety were secondary themes. Our review suggests that a model of unintended pregnancy containing social-ecological aspects can describe predictors of pregnancy and potential prevention strategies. Furthermore, the future exploration of the challenges that African American women living with HIV experience with unintended pregnancies, efforts to manage their condition and prepare for a pregnancy are needed. / Public Health

Purpose: Unintended pregnancies are often a burden to pregnant women and to the health care system. The rates of unintended pregnancies have decreased since the wide use of contraceptives has increased; however, young women, women with low income, and racial/ethnic minorities are more likely to use contraceptives inconsistently, which increases the risk of an unintended pregnancy. This risk could be reduced with the proper use of emergency contraceptives (ECs).Methods and Analysis: A cross-sectional study was conducted using the data from the female respondents of the 2002 Cycle 6 NSFG. Logistic regression was used to determine rates of use of ECs among different risk groups. A second analysis only including women who have had an abortion in the past 12 months was also conducted.Results: In the total study population, women over the age of 30 were more likely to never have used ECs, to not have used ECs in the past 12 months, and to not have received EC counseling in the past 12 months. Among those who have had an abortion, women aged 15-19 were less likely to have never received ECs. Those aged 15-19 and 30-34 were less likely to not receive EC counseling. Income level did not have a significant effect on use of EC services. For the whole study population, Hispanic women were significantly less like to not receive ECs in the past 12 months. Hispanic women were also less likely to not receive EC counseling in the past 12 months for the total study population and for those who have had an abortion.Discussion: Unintended pregnancies create burden for individuals as well as the public health infrastructure. ECs could help to prevent some of these unintended pregnancies. Age was the most significant and consistent predictor of use of EC services Further research should focus on evaluating the use of ECs specifically among those who have unprotected sex in order to more precisely evaluate the characteristics of women using and not using ECs. Further research into the barriers preventing women from accessing ECs is also necessary to increase use of ECs and prevent unintended pregnancies.

Diante da importância que a gravidez não planejada vem adquirindo no cenário mundial, apesar da melhoria nas tecnologias contraceptivas e ampliação do acesso aos serviços de saúde e métodos contraceptivos, faz-se necessário mensurar com maior precisão este fenômeno. Por esta razão, pesquisadores da área de saúde sexual e reprodutiva têm procurado desenvolver medidas que possam oferecer estimativas confiáveis de mulheres que vivenciam a gravidez não planejada. A maior parte dos instrumentos utilizados para mensurar a gravidez não planejada são unidimensionais e não levam em consideração a parceria, a intencionalidade ou o uso de métodos anticonceptivos de forma simultânea, aspecto não observado no London Measure of Unplanned Pregnancy (LMUP), desenvolvido no Reino Unido. Nesse contexto, este estudo transversal tem como objetivo traduzir e adaptar o instrumento LMUP para a língua portuguesa e validar suas propriedades, visando à sua utilização como instrumento de mensuração de gravidez não planejada no Brasil. A adaptação cultural e validação do LMUP foram realizadas conforme o método preconizado pela literatura. O cenário de estudo foram unidades da rede de Atenção Básica do município de Marília-SP. A população de estudo foi composta por 126 mulheres com idade 18 e 42 anos, usuárias dessas unidades, que procuraram a Unidade para confirmação do diagnóstico da gravidez por meio de um teste imunológico para gravidez cujo resultado foi positivo. Os resultados obtidos demonstraram que em relação às propriedades psicométricas, o instrumento apresenta um valor de apha de Cronbach de 0,75 para a escala total. A análise fatorial exploratória dos componentes principais do instrumento LMUP na versão Português aqui apresentada resultou em um único fator, que explicou 66,5% da variância total dos dados. As propriedades psicométricas do instrumento foram demonstradas e, portanto ele pode ser utilizado para mensurar a gravidez não planejada na população brasileira. / Facing the impact that unplanned pregnancy is acquiring world wide, despite the improvement in contraceptive technologies and increasing access to health services and contraceptive methods, it is necessary to measure this phenomenon more accurately. For this reason, researchers in the sexual and reproductive health field have sought to develop measures that can provide reliable estimates of women experiencing unplanned pregnancies. Most instruments used to measure the unplanned pregnancy are unidimensional and do not take into account the partnership, the intent or the use of contraceptive methods simultaneously, a not observed aspect at London Measure of Unplanned Pregnancy (LMUP), developed in the United Kingdom. Thus, this cross-sectional study is aimed to translate and adapt the instrument LMUP to Portuguese and validate its properties, aiming at its use as an instrument for measuring unintended pregnancy in Brazil. Cultural adaptation and validation of LMUP were done according to the method recommended by the literature. The scenery for the study was units of the network of Primary Care in Marília-SP. The studied population consisted of 126 women aged between 18 and 42 years, users of these units, who sought for this Unit to confirm the diagnosis of pregnancy by means of an immunological test for pregnancy and the result was positive. The results showed that in relation to psychometric properties, the instrument has a Cronbach\'s alpha value of 0.75 for the total scale. The factor analysis of the main components of the LMUP to the Portuguese version presented here has resulted in one factor, which explained 66.5% of the total variance of the data. The instrument\'s psychometric properties were demonstrated, and, therefore, it can be used to measure the unplanned pregnancy of the Brazilian population.

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.