published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

This study adopted a case study design to understand women and contraceptive use in the Diepsloot community, an impoverished urban informal settlement, north of Johannesburg. It was guided by feminist and critical theory, and made use of the qualitative research paradigm. The history of the provision of reproductive health services in South Africa has been discussed as a process that has both marginalised the participation of previously disadvantaged communities and also limited the opportunities for effective contraceptive use in the post-apartheid era. The main objectives were to understand reproductive health experiences of women and their knowledge of modern contraception in relation to the ecological environment in which they are embedded. I used the non-probability purposive and theoretical sampling methods. The sample size was theory driven and largely determined by the type of data acquired after a series of interviews with twenty women over a five month period. Data collection ceased when data saturation was reached. Individual interviews and focus group discussions were conducted with twenty primary respondents. For triangulation purposes, primary health care service providers from the two local clinics were interviewed. Also one focus group discussion was done with a group of eight men; two traditional healers and the manager at the local Marie Stopes clinic were also interviewed for the same purpose. I used thematic analysis as the method of analysing the data. Thematic analysis moves beyond merely describing the data but identifies both the unspoken and obvious ideas within data. It was the intersectionality of contraceptive use and the unique lived experiences of disadvantaged women that had inspired the study and all methods employed were aimed at a deeper understanding of the effects of the cultural, social and economic environment on the reproductive health choices of the women. The data were analysed according to the seven themes that emerged from the study and these were: empowerment and reproductive health decision making, level of education as a determining factor in contraceptive use, contraceptive knowledge, contraceptive dialogue as a contributing factor to contraceptive use and choice, opinions on the prevention of pregnancy, spacing versus limiting the number of births and the availability and accessibility of modern contraceptive methods. The inextricable link between education, poverty and gender inequality highlighted the need to empower women in marginalised communities. Due to poverty and lack of education, most women were powerless and not independent to make favourable reproductive health decisions. Knowledge of modern contraceptive methods was limited and the most popularly used method was the contraceptive injection. The circumstances of the women in this study and those of the Diepsloot community speak to the broader economic issues of the country and reflect the need to prioritise women’s education; to create economic opportunities for women and to enhance the participation of the poor and marginalised communities. / Thesis (M.A.)-University of KwaZulu-Natal, Durban, 2012.

<p>Background: In Namibia, studies showed that HIV/AIDS affects youth, especially the under 24 years age group. At the same time the pregnancy rate is also high by age 19. Interestingly, in&nbsp / Andara district several reports from staff working in the reproductive services have indicated that adolescent girls, who would seem to be taking responsibility in one sphere of their sexual lives&nbsp / by protecting themselves against unwanted pregnancy, were however not using condoms to protect themselves from HIV infection. Study Aim and Objectives: To describe the knowledge, attitude and behaviour related to HIV/AIDS amongst female adolescents who are accessing the primary health care (PHC) services for contraception. Specific objectives were to describe the&nbsp / knowledge of female adolescents who are accessing the PHC services for contraception about the modes of transmission and prevention of HIV/AIDS, to assess their attitude with regards to&nbsp / condom use, abstinence and being faithful to one uninfected partner, also to determine the significance of association between age and knowledge, attitudes and behaviour, between their&nbsp / education level and knowledge, attitudes and behaviour and the significance of association between knowledge of HIV prevention strategies and&nbsp / behaviour of female adolescents accessing&nbsp / &nbsp / PHC services for contraception in the district. Setting: The study was conducted in Andara district, North East of Namibia. Methods: Descriptive cross-sectional KAB study. Sample: All female&nbsp / adolescents who are accessing PHC services for contraception selected from multistage simple random sampling in 5 facilities and systematic sampling at facility level in Andara. All married&nbsp / women within this age range were excluded in the study. Data collection tool: An interviewer-administered standardised questionnaire was used to collect the data. Data analysis and&nbsp / Interpretations: Epi Info software 2002 was used for data analysis. The results were presented using descriptive statistics including means, 95% confidence intervals and percentages and&nbsp / this information was shown in tables, bar and pie charts. Cross-tabulations of knowledge, attitude and behaviour scores against demographic variables were performed. P-values &lt / 0.05 were&nbsp / &nbsp / considered statistically significant. Results: 76.5% knew that unprotected sexual intercourse was the main way of getting HIV/AIDS, 77.3% knew that people could protect themselves by&nbsp / abstaining from sexual intercourse and 64.5% knew that people could protect themselves by having one uninfected faithful sexual partner. Out of 192 respondents who stated that unprotected&nbsp / sexual intercourse was the main way of HIV/AIDS transmission, 25.5% used condom every time they had sexual intercourse, 10.9% used condom almost every time they had sex, 41.1% used&nbsp / condom sometimes and 22.4% never used condom. Older girls and those who were in higher grades at school had more knowledge that could protect them from HIV infection. Later sexual&nbsp / debut is associated with increased&nbsp / condom usage at sexual debut. Conclusions: The general HIV knowledge of respondents and their knowledge of how to&nbsp / protect themselves from HIV infection were disappointing given that this&nbsp / study was conducted in health facilities. In this study we also see that knowledge does not always translate into the appropriate behaviour. The health services need to evaluate the targeting and&nbsp / effectiveness of their HIV educational messages and develop skills that will support behaviour change.&nbsp / </p>

This thesis explores issues of contraceptive use among members of both male and female genders. Although research has been conducted on teenage pregnancy, abortion, sexual behaviour, and contraceptive use with particular focus on the female population, a gendered study has yet to be conducted on contraceptive use among young adults, male and female that have just gone beyond their teenage years and are on the verge of entering into adulthood. Hence, this thesis reviews contraceptive use among young adult students (aged 18-25) of both genders using quantitative (survey) and qualitative (interviews) research methods. This study was based at the University of Natal, Pietermaritzburg. A total of forty students (n=40) were sampled using the convenience sampling method. Twenty of the students were male, while the remaining twenty were female. The thesis adopts a theoretical approach that attempts to conceptualise the influence of patriarchy on contraceptive use among members of the female gender. Also, societal reproductive role fixing is contemplated by examining the ways through which societal construction of male and female roles and stereotypes affect contraceptive use among members of both genders. In this study, it is affirmed that societal attitudes, and misconceptions about contraceptive use play an important role in young adult, male, and female contraceptive use and attitudes towards. Evidence of this, from the survey and interviews conducted in the study, is the high use of the condom, amongst both male and female students compared with other available methods. Among female students, the use of the pill is at twenty-three percent (n=6), use of injectable methods is at thirty-one percent (n=8), while the use of the condom is considerably higher at fortysix percent (n=12). While among male students, the use of the withdrawal method is at nineteen percent (n=4), while condom use is at eighty-one percent (n=17). Both male and female reported that they were satisfied with their choice and use of contraception. The response rate for satisfied female clients was eighty-five percent (n=22), while among male clients, it was seventy-six percent (n=16). The high use of the (male) condom among female students was highly attributed to personal convenience and comfort with condom use as unmarried young women. While with both genders, with the male especially, it was attributed to the function of the condom as a safe sex method, rather than for pregnancy prevention Gender is, and will remain a relevant issue in sexual/reproductive health matters globally. This work represents a contribution to knowledge in this field. / Thesis (M.A.)-University of Natal, Durban, 2003.

Women seem to be largely protected against certain ‘welfare disorders’ such as cardiovacular disease and osteoporosis, during their fertile years.The metabolic changes observed during women’s non-menstrual states, i.e. during pregnancy, after the menopause and during use of oral contraceptives, indicate the importance of sex steroids and an undisturbed biological rhythm. Treatment with monophasic, combined oral contraceptives constitutes a model for the non-cyclic state.Growth hormone (GH) is a pituitary hormone that has major metabolic effects. The pattern of GH exposure to the target organ is of vital importance for the effects and changes in rhythm could possibly induce metabolic changes.Growth hormome, cholecystokinin (CCK), osteocalcin and angiotensinogen were used as markers for metabolic effects and the concentrations in serum were recorded in women during non-menstrual states. The clinical material comprised a total of 60 women: 18 healthy non-pregnant, 25 pregnant, one lactating woman and 16 postmenopausal women. Using a portable pump and a non-thrombogenic venous catheter, blood samples could be collected at 30-min intervals during 24-h periods. Furthermore, the effects of estrogen and GH in the regulation of angiotensinogen were investigated in an experimental model in the rat.Oral contraceptives were found to alter the secretion of GH towards a pattern of lower and more frequent peaks, though the total amount secreted during 24 h was unchanged. Oral contraceptives seem to induce a suppression of the 24-h concentrations of CCK, which may be important with respect to weight gain in some women. Osteocalcin in serum display a significant circadian variation. This emphasizes the need for careful timing of single point measurements and the value of continuous blood sampling. Oral contraceptives may reduce osteocalcin serum concentrations. The long-term effects on bone are unknown. During late pregnancy osteocalcin levels are extremely low, which could indicate osteoblast inhibition and reduced bone turnover. The mode of GH administration is important for the plasma concentration of angiotensinogen in the non-pregnant rat. Estrogen effects on this protein may be mediated via a modification of GH secretion. Oral contraceptives not only increase angiotensinogen concentrations in serum but also markedly enhance their variability. Further studies are needed to elucidate the relation between the individual pattern of angiotensinogen and hypertension. / <p>S. 1-42: sammanfattning, s. 43-88: 6 uppsatser</p> / digitalisering@umu

Formål: Vurdere om etterutdanningen, som gir helsesøstre og jordmødre rekvireringsrett for p-piller til jenter i alderen16 til og med 19 år, har bidratt til økte kunnskaper om p-piller, endret holdning til ungdom og seksualitet og økt interesse for å tilby veiledning i samliv og seksualitet. Metode: Datamaterialet er fra en tidligere undersøkelse innhentet ved bruk av spørreskjemaer blant helsesøstre og jordmødre før og etter kvalifiserende etterutdanning. Resultater: Svarprosenten var 94. Studentene har tilegnet seg signifikant mer kunnskap om p-pillers virkning og fysiske og psykiske bivirkninger, men de har ikke tilegnet seg signifikant mer kunnskap om risiko for alvorlige sykdommer ved p-pillebruk. Etter kurset var det 58 og 50 % som svarte at tenåringsjenter trenger informasjon om faren for blodpropp i henholdsvis bein og lunger ved bruk av p-piller. Studentene var relativt liberale i sitt syn på ungdom og seksualitet før kurset og dette hadde ikke endret seg signifikant etter kurset. Etter kurset var studentene signifikant mer positive til å tilby veiledning i samliv og seksualitet. Konklusjon: Resultatene viser at målet om at kurset skulle gi studentene faglig oppdatering er bare delvis nådd. Studentene er blitt bedre kvalifisert til å informere om p-pillers virkning og fysiske og psykiske bivirkninger, mens deres kunnskap om risiko for alvorlige sykdommer ved p-pillebruk er uforandret etter kurset. Studentene viser etter kurset signifikant større interesse for å tilby veiledning i samliv og seksualitet / Purpose: To examine whether the qualifying postgraduate course, which authorizes public health nurses and midwives to prescribe oral contraceptives to teenage girls 16–19 years of age has increased the students’ knowledge of oral contraceptives, contributed to changing their attitude to adolescence and sexuality, and increased their motivation for offering teenage girls counselling in sexuality and sexual relationships.Method: The data set used for this study is a previously existing survey collected among public health nurses and midwives through questionnaires administered before and after they completed the course.Results: The response rate was 94 %. The students significantly increased their knowledge about effects and physical and psychological side effects of using oral contraceptives, but did not about the risk of serious diseases that accompanies oral contraceptive use. After the course, 58% and 50 % of the students found it necessary to inform teenage girls about the risk of blood clots in legs and lungs, respectively, when using oral contraceptives. The students’ attitudes towards youth and sexuality were quite liberal before the course and the course did not significantly change those attitudes. Moreover, students were significantly more positive about offering teenage girls counselling regarding sexual relationships and sexuality.Conclusion: The results demonstrate that the purpose of the course, i.e. upgrading students’ qualifications, is only partly successful. Although the students are significantly better qualified to inform teenage girls about oral contraceptives effects and their side effects, their knowledge about the risk of serious diseases did not increase significantly. The students show significantly more interest in offering counselling about sexual relationships and sexuality after completing the course. / <p>ISBN 978-91-85721-71-9</p>

High-risk alcohol consumption in combination with unprotected sexual activity can have deleterious results for the individual, their family and their larger community. In this investigation, a secondary analysis was performed on the female data of Wave 3 of the Healthy Youth Survey to determine rates of female drinking and unprotected sex and to create a predictive model of high-risk drinking behaviour. Three dependent variables were examined: heavy drinking, weekly binge drinking and having a CAGE score of 2 or more, and Jessor and Jessor's (1977) Problem Behaviour Theory is drawn on in the interpretation of results. Age, the influence of negative peers, physical victimization, and the presence of an addiction-prone personality were found to be predictive of engaging in heavy drinking and weekly binge drinking; the influence of negative peers was found to be predictive in having a CAGE score of 2 or more. A difference in contraceptive use was only found for the young women engaging in weekly binge drinking. The results of this study highlight the importance of how different drinking styles can impact the likelihood of engaging in high-risk sex.

The Bureau of Land Management (BLM) maintains a growing number of feral horses on public rangelands. With population growth rates as high as 22% annually, herds are exceeding their carrying capacity and millions of dollars are spent maintaining captured horses in holding facilities awaiting adoption. To manage the feral horse population, the BLM is seeking a contraceptive that is safe, can be remotely delivered, requires only a single administration and is effective for several years. Contraceptive strategies have been developed for feral horses that include hormone implants, chemical intrauterine devices, and immunocontraception. Porcine zona pellucida (pZP) immunocontraceptive vaccines have shown great potential for providing safe, long-term contraception in feral horses. ImmunoVaccine Technologies (Halifax, Nova Scotia, Canada) has developed a liposome encapsulated pZP formulation known as SpayVac™ (SpayVac), which after a single-dose provides multi-year contraceptive efficacy. In a continued effort to optimize the acceptability and efficacy of SpayVac, ImmunoVaccine Technologies developed alternative adjuvant preparations using either killed Mycobacterium butyricum (Modified Freund's Adjuvant; MFA) or a proprietary non-Mycobacterium based adjuvant (IVT) that are proposed to have less of the undesirable side-effects associated with Mycobacterium tuberculosis. Therefore, the objective of this research was to evaluate SpayVac in different adjuvant formulations for efficacy of contraception as measured by pZP titers and estrous cyclicity in treated mares. Domestic mares (n=28) were randomly assigned to four treatments (7 mares per treatment): adjuvant alone or saline (Control) or SpayVac vaccines in one of three adjuvant preparations: IVT or MFA in either an aqueous (MFA aq) or non-aqueous (MFA non-aq) suspension. Pre-immune blood samples were collected from each mare and mares were injected in the neck with a single injection of the Control or SpayVac. Subsequent blood samples were collected at weekly intervals for 26 weeks. Sera were analyzed for pZP titers and progesterone using ELISA. At the conclusion of the study, ovaries were recovered by ovariectomy (16 mares) or at necropsy (12 mares) for histologic analysis and collection of morphometric data and oocytes. Titers for pZP were greater (P<0.05) in IVT and MFA mares compared to Control mares and for MFA compared to IVT mares. Mares vaccinated with MFA aq had greater (P<0.05) pZP titers at 2 weeks post-injection compared to mares injected with IVT or MFA non-aq and at 3 weeks post-injection compared to mares injected with IVT. MFA non-aq mares had greater (P<0.05) pZP titers at 6 weeks post-injection compared to IVT mares and, although not significantly different, titers in MFA non-aq mares remained greater during weeks 8, 10, 14, 18 and 22 compared to IVT and MFA aq mares. Mean serum progesterone concentrations were greater (P<0.05) in Control compared to MFA non-aq mares. Mean ovarian weights, oocyte diameters, zona pellucida thicknesses and the number of horse sperm bound to oocytes recovered from vaccinated mares were greater (P<0.05) in Control mares compared to IVT and MFA mares. As judged by pZP titers and serum progesterone, these results suggest that SpayVac suspended in the MFA non-aqueous formulation exerted the greatest contraceptive effects in treated mares. This preparation of SpayVac may meet the criteria cited by the BLM for their most desirable immunocontraceptive. / Graduation date: 2012

Master of Medicine / The number of unwanted pregnancies has not decreased in recent years and this should be addressed. Emergency contraception may be effective when used correctly having the advantage that it can be used after an episode of unprotected sexual intercourse (when regular contraception has failed or was not used). In this research project I set out to explore some of the major reasons why there are still many unwanted pregnancies in Australia. I decided to focus on the use and non-use of emergency contraception, e.g. emergency contraception pill (ECP) “method failures” are not well understood because the actual mechanisms of action are still unclear. There is evidence ECP can effectively interfere with follicle growth and ovulation. It is much less clear is whether ECP is able to interfere with fertilization and implantation, in a way, which may make it acceptable to those who have strong religious beliefs in fertilization being the start of new life. Emergency contraception has the potential to prevent many unwanted pregnancies when unprotected intercourse has occurred. It has relatively high efficacy in many studies, but true method failures are not well understood. By contrast, many unwanted pregnancies occur for “social reasons” where emergency contraception has not been used. I set out to study changes in knowledge and usage of emergency contraception in these groups of Australian women seeking termination of pregnancy: 1. Before a dedicated emergency contraception pill (ECP) pack (Postinor) became available in Australia 2. One year after dedicated ECP became available on prescription 3. One year after the ECP pack became available “over the counter” without prescription. Ninety-nine women were recruited during their presentation with a request for ECP at the six Family Planning Clinics in Australia. All women took LNG 1.5mg in a single dose during the clinic consultation. A blood sample was taken immediately prior to ingestion of the ECP for estimation of serum LH, oestradiol and progesterone levels to calculate the day of the menstrual cycle. Based on these endocrine data we estimated the timing of ovulation to within a ±24-hour period with an accuracy of around 80%. Women were followed up 4-6 weeks later to ascertain pregnancy status. The effectiveness of ECP when taken before and after ovulation was determined. Three women in this study became pregnant despite taking the ECP (pregnancy rate 3%). All three women who became pregnant had unprotected intercourse between day -1 and 0 and took the ECP on day +2, based on endocrine data. Day zero was taken as ovulation day. Among seventeen women who had intercourse in the fertile period of the cycle and took the ECP after ovulation occurred (on day +1 to +2) we could have expected 3 or 4 pregnancies, based on Wilcox et al data. Three pregnancies were observed. Among 34 women who had intercourse on days –5 to –2 of the fertile period, and took ECP before or around ovulation, four pregnancies could have been expected, but none were observed. The major discrepancies between women’s self-report of stage of the cycle and the dating calculation based on endocrine data were observed in this study. These data are supportive of the concept that the LNG ECP has little or no effect on post-ovulation events, but is highly effective before ovulation. Our interpretation of the data in terms of timing of treatment relative to ovulation may explain why EC with LNG works sometimes and fails at other times. A larger study is needed to prove this hypothesis. To investigate other reasons for such a high rate of unwanted pregnancy, which probably has a larger impact we looked into womens knowledge of and attitude towards ECP. Seven hundred and eighteen women participated in this study by answering a questionnaire consisting of 15 questions on their demographic and reproductive characteristics as well as the knowledge about the ECP, e.g. 208 women were enrolled before the ECP was marketed in Australia in 2001, 308 after it was marketed and 202 after it became available over the counter (Group 1, 2, and 3, respectively). We found that the participants who have heard about ECP were significantly younger (p<0.005). The mean age of women who have never heard about of ECP was 29.8 years compared to 26.3 years in women who have heard about ECP. More women were aware about the ECP after it became available over the counter. Women in group 2 had higher educational level in comparison to women in group 2 and 3 (p<0.005). There was significant trend in increased use of ECP in women of higher educational level (p<0.005). The use of ECP did not increase significantly with improved availability and access to the ECP amongst women presenting for termination of pregnancy. Wider availability of he ECP pack in Australia and an easier access to it has increased women’s awareness about the ECP. However, the use of ECP has not increased. This study provides better understanding of mechanism of action of LNG ECP and an explanation to the method failure. It also reveals poor knowledge about ECP despite its wider availability and accessibility. Improving these is a worldwide challenge for family planners and all health professionals.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 4 uppsatser.