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By C. Kalesch. University of Guam.

Hyperbaric oxygen (100 per cent) accelerates damage in proportion to atmospheric pressures used (Ganong 1995) 20 mg cialis sublingual amex erectile dysfunction forum. Most intensivists limit prolonged (over 24 hours) oxygen exposure to 50–60 per cent whenever possible purchase cheap cialis sublingual on line erectile dysfunction underwear, meeting oxygen demand through adjusting other supports (e order 20 mg cialis sublingual erectile dysfunction treatment canada. Hyperoxia can be detected by blood gas analysis buy cialis sublingual with visa erectile dysfunction after zoloft, but not pulse oximetry, due to the sigmoid relationship between SaO2 and PaO2 (the oxygen dissociation curve) (Hough 1996). Carbon dioxide transport This chapter concentrates on oxygen rather than carbon dioxide carriage, oxygen being vital for life, whereas carbon dioxide is a waste product of metabolism. Carbon dioxide carriage is also relatively more simple than the carriage of oxygen. Normal blood concentrations vary between 48 ml per decilitre (arterial) to 52 ml/decilitre (venous) (Green 1976), a narrow pressure differential. Carbon dioxide is twenty times more soluble than oxygen, enabling rapid diffusion (and so removal) across capillaries (Hough 1996). Carbon dioxide binds to globin, not haem, so unlike carbon monoxide does not displace oxygen. Like the oxygen dissociation curve, carbon dioxide dissociation can move to the right or left. Rightward shifts (favouring dissociation of oxygen from haemoglobin) occur with raised levels concentrations of oxygen in blood. Haemoglobinopathies Critical illness is frequently complicated by haemoglobinopathies; four are described here. Methaemoglobin shifts the oxygen dissociation curve leftwards, reducing oxygen availability for tissues. Oxidation can be caused by various drugs, including lignocaine, nitrates and metoclopramide (Adam & Osborne 1997) and nitric oxide. Methaemoglobin causes pulse oximetry readings of 85 per cent, regardless of arterial oxygen saturation (Wahr & Tremper 1996). The half-life of carbon monoxide in air is 250 minutes; this time can be reduced by increasing oxygen concentration or atmospheric pressure (see Chapter 29). Thalassaemia may also be classified as major, intermedia or minor, depending on its severity. The genetic defect reduces erythrocyte life (Buswell 1996), thus reducing erythrocyte concentration below 2 million per cubic millimetre (Marieb 1995). Since anaemia is caused by lack of erythrocytes, traditional treatment has been blood transfusion to increase haemoglobin concentration. However, frequent transfusion can cause iron overload (Buswell 1996), and so desferrioxamine (an iron chelator) helps to prevent hepatic failure. Splenectomies may be performed where erythrocyte destruction exceeds production, and younger patients may receive bone marrow transplant if a sibling or parent is HbA compatible. Sickle-shaped erythrocytes can occlude small capillaries, causing necrosis, infarction and ischaemic pain in tissue beyond occlusions. Cerebral and renal microcapillaries are at special risk; small peripheral blood vessels often cause intense pain. Sickle genes cause erythrocytes infected by malarial parasites to adhere to capillary walls, denying parasites the potassium they need to survive. Sickle cells provide protection from malaria (Marieb 1995), and so this mutation has flourished in the malarial belt. Sickle cell crises may occur with any hypoxic stressor, such as exercise, altitude, surgery, anaesthetic gases or critical illness. Crisis carries a significant mortality, so that although people with both haemoglobin chromosomes (HbS, HbS) are most at risk, people with sickle cell trait (HbS, HbA) can sickle with extreme hypoxia. Crisis management focuses on providing: ■ analgesia ■ oxygen ■ fluids ■ blood (exchange) transfusion Sickle crisis pain is intense, requiring strong analgesia. Traditionally, pethidine was used, although poor absorption and tolerance reduce benefits below the usually cited two hours, Gas carriage 163 so morphine is increasingly used (Thomas & Westerdale 1997). Despite anecdotal concerns about addiction and feigning crises to obtain opiates, benefits from analgesia to those in crisis far outweigh risks from drug abuse (see Chapter 7). The delivery of oxygen to ischaemic tissues relieves ischaemic pain and prevents further damage (although reperfusion injury may damage tissue—see Chapter 26). Giving intravenous fluids to increase blood volume and reduce viscosity, while optimising alveolar oxygen, favours oxygen delivery. The complex dissociation of oxygen has been discussed in this chapter; the dissociation curve will be referred to in some later chapters to help nurses apply its principles to bedside care. Although carbon dioxide is carried through three mechanisms, its dissociation is relatively linear and simple. Blood gas analysis is widely used to assess both respiratory and metabolic function. Non-invasive and continuous display technology may replace intermittent arterial sampling, but components measured are likely to remain, and so have been described. Nurses can valuably develop their skills with blood gas analysis by working through samples from practice, remembering to apply information within the context of the whole patient. Articles on haemoglobinopathies appear periodically in nursing journals (Thomas & Westerdale 1997); further information can be obtained from the support groups mentioned above. This chapter begins with a discussion of acid-base balance, goes on to suggest briefly good practice for taking arterial blood gas samples, and then discusses other results commonly found in blood gas analysis. Like many other aspects of practice, the technology for blood gas analysis varies, as does the data used between units. Acid-base definitions An acid is a substance capable of providing hydrogen ions; a base is capable of accepting hydrogen ions. Acid-base balance, therefore, is the power of hydrogen ions (pH) measured in moles per litre (‘power’ used in the mathematical sense, for the negative logarithm). The power of hydrogen ions can be controlled (balanced) either through buffering or exchange. Hydrogen is a positively charged ion (cation) which can be buffered by negatively charged ions (anion) such as bicarbonate. Hydrogen may move into another body compartment, either through pressure gradient differentials or in exchange for similarly charged ions. The only other significant cations in the human body are sodium and potassium, while the only significant anions are chloride and bicarbonate. Intensive care nursing 166 pH measurement Hydrogen ion concentrations in body fluids are about one million times less than concentrations of other ions (Hornbein 1994). Despite these very small concentrations, hydrogen ions are highly reactive, with small changes in concentration creating significant changes in enzyme activity (Hornbein 1994) and oxygen carriage (the Bohr effect—see Chapter 18). With plasma concentrations being so small, ions are measured by a negative logarithm. Thus, the log to the base 10 represents multiples of 10 by a power: Increasing one figure in the power represents a tenfold increase in the actual number. Negative logarithms use the same principle to manage very small numbers, so that: Acid-base balance and arterial blood gases 167 Normal plasma concentrations of 0. While the pH scale enables concentrations of huge ranges within confined limits of 0–14 (absolute acid to absolute alkaline), small alterations in pH can significantly alter hydrogen ion concentrations. With homeostasis, arterial pH maintains a bicarbonate to carbon dioxide ratio of 20:1 (Prencipe & Brenna, undated). Because minute concentrations of hydrogen ions have such profound effects, blood pH needs to be maintained within very narrow ranges—usually given as 7. Blood below this range is therefore termed ‘acidotic’, even though chemically it remains alkaline until reaching a pH of 7. Metabolism produces about 40–80 nmol of hydrogen each day (Marshall 1995), creating a concentration gradient between intracellular (highest) levels and plasma. Although chemically useful, extremes of human life have narrow pH ranges: Marieb (1995) cites 7. Homeostasis, therefore, aims to maintain levels within physiological levels of about 7. Acid-base balance is controlled through three mechanisms: ■ respiratory ■ renal ■ chemical buffering Respiratory control In the lungs, carbonic acid, being unstable, dissociates into water and carbon dioxide: Thus, partial pressure of carbon dioxide in plasma indicates carbonic acid level, and carbon dioxide is therefore considered a potential acid (lacking hydrogen ions, it is not really an acid). Intensive care nursing 168 The body produces 15,000–20,000 mmol of carbon dioxide each day (Coleman & Houston 1998). Hypercapnia stimulates medullary chemoreceptors, thus stimulating the respiratory centre to increase rate and depth of breaths, which removes essential components of carbonic acid. Although respiration cannot remove hydrogen ions, it can inhibit carbonic acid formation, so restoring homeostasis. Respiratory acidosis is caused either by lung disease (impairing carbon dioxide exchange) or hypoventilation. Respiratory alkalosis is caused by hyperventilation (high rate, tidal/minute volume). Respiratory response to acidosis occurs within three minutes of imbalance, exerting up to double the effect of combined chemical buffers (Marieb 1995). Renal control The kidneys actively contribute to acid-base balance in two ways: ■ hydrogen ion excretion ■ chemical buffering (producing and reabsorbing filtered bicarbonate and phosphate) and passively remove water (the remaining product of carbonic acid dissociation following respiratory removal of carbon dioxide). Although respiration controls carbonic acid, hydrogen ions can only be removed from the body by the kidneys, where they are actively exchanged for other cations, primarily sodium. Since potassium competes with hydrogen for sodium exchange, hyperkalaemia competes with acidosis for clearance of excess cations. The normal renal excretion of hydrogen ions is 30–70 mmol each day (Raftery 1997), although levels can reach 300 mmol per day within 7–10 days (Worthley 1997). This enables metabolic (renal) compensation for prolonged respiratory acidosis (e. Tubular selective reabsorption preserves most bicarbonate ions; the kidney also generates bicarbonate ions, so that renal failure can cause potentially profound metabolic acidoses. Chemical buffers respond rapidly, within seconds, balancing hydrogen ions by binding acids to bases, but do not eliminate acids from the body.

In women order 20mg cialis sublingual visa laptop causes erectile dysfunction, the rate of loss accelerates for several years after menopause buy cialis sublingual overnight delivery biking causes erectile dysfunction, and then slows again buy cialis sublingual 20 mg online erectile dysfunction drug samples. The trabecular bone normally looks like a honeycomb buy cialis sublingual 20mg free shipping erectile dysfunction treatment charlotte nc, but in those with osteopo- rosis the spaces in that honeycomb grow larger because more bone is destroyed than replaced. There are many factors that contribute to and accelerate bone loss, and much that can be done to prevent this disease. Since bone health affects our mobility and ability to carry out daily activities, it is important to learn how to prevent osteoporosis and maintain strong, healthy bones throughout life. Once the bones have become weakened, osteoporosis may cause back pain, collapsed vertebrae, loss of height, and spinal deformities. For those with osteoporosis or osteopenia with strong risk factors for osteoporosis, drug therapy may be recommended to either slow the rate of bone loss or promote bone development. There are a variety of medications that doctors prescribe, such as hormones and bisphosphonates (such as etidronate). Examples include canned fish with bones (salmon and sardines), dark-green vegetables (kale, kelp, collards, broccoli, and Brussels sprouts), and calcium-fortified orange juice and soy milk. Some studies have shown that people who get their calcium from plant sources have lower rates of osteoporosis. Many people have difficulty digesting lactose, the sugar in milk, and some are allergic to the protein in milk. Another concern is that dairy cows can be injected with hormones and antibiotics, which pass into their milk. Those who can tolerate milk should choose fat-free, organic milk and cheese to avoid ingestion of these substances. Recent research suggests that polyphenols (plant pigments) in fruits, vegetables, green tea, and red wine have a positive effect on bone-building cells. Food sources include leafy green vegetables, whole grains, nuts, seeds, meat, milk, soybeans, tofu, legumes, and figs. Food sources include fortified milk products and breakfast cereals, fatty fish, and eggs. O • Soy foods such as tofu, soy milk, roasted soy beans, soy powders, and soy bars can also play a role in the prevention of osteoporosis. Soy contains isoflavones, which are plant- based estrogens that protect against bone loss. Foods to avoid: • Caffeine (more than three cups coffee per day) or sodium can increase calcium loss through urination, accelerating bone deterioration. Lifestyle Suggestions • Weight-bearing activities, which place stress on the bone, help to strengthen bones and improve bone density. Exercise also increases muscle strength, coordination, and balance, helping to preserve mobility and reduce the risk of injury and fracture. Top Recommended Supplements Calcium: Essential for bone health; since it may not be possible to get adequate amounts through diet, supplements may be necessary. Recommended intake for men and women ages 19–50 is 1,000 mg daily and 1,500 mg over age 50. Many products combine calcium with other nutrients for bone health such as vitamin D and magnesium. Separate calcium-rich foods and supplements by two hours from iron supplements (calcium reduces iron absorption). Numerous studies have found that it prevents bone loss and reduces bone pain caused by osteoporosis and fractures. Those who are taking medications or have medical conditions that impair vita- min D absorption may require higher amounts. O Complementary Supplements Fish oils: Recent research suggests that fish oils increase both calcium absorption and im- prove calcium’s delivery to the bones. Vitamins D, K, B6 and B12, boron, copper, manganese, phosphorus, folate, magnesium, silicon, and zinc are also required. As well, new research suggests that fish oils increase both calcium absorption and improve calcium’s delivery to the bones. To strengthen your bones and protect yourself against this disease, consider the following: 1. The ovaries are two, small almond-shaped organs located on each side of a woman’s uterus that produce eggs and female hormones. When an egg is mature, the follicle breaks open to release the egg, and then dissolves. If the follicle doesn’t break open to release the egg, it forms a follicular cyst. If pregnancy doesn’t occur, the corpus luteum normally breaks down and disappears. If this does not happen and fluid builds up in the cor- pus luteum, it can form a cyst. These cysts can grow to almost 10 cm and may cause bleeding or twist the ovary and cause pain. Other types of cysts include: Cystadenomas: Cysts that develop from cells on the outer surface of the ovary. They are often filled with a watery fluid or thick, sticky gel and can become large and painful. Endometriomas: A type of cyst that develops in women with endometriosis, a condi- tion where tissue from the lining of the uterus grows outside of the uterus. Polycystic ovarian syndrome: Multiple cysts appear on the ovaries due to hormonal imbalance and high insulin levels. Many women have ovarian cysts at some time during their lives and most ovarian cysts are benign (non-cancerous) and disappear without treatment. For this reason, knowing the signs and symptoms and having regular pelvic exams is important to preserving ovarian health. If you develop sudden and severe abdominal or pelvic pain along with fever or vomiting, O seek immediate medical attention. Follicular and corpus luteum cysts are usually just monitored by the doctor and go away on their own. Oral contraceptives or progesterone cream are sometimes given to women who get frequent cysts as a way of controlling hormone levels and preventing cyst growth. Surgery is usually considered as a last resort for women with malignant cysts, those who have very large cysts that do not go away, and those with severe symptoms or infertility. Foods to avoid: • Meat and dairy products may contain saturated fat, hormones, and chemicals that can affect ovarian health and trigger inflammation. O Top Recommended Supplements There is limited research on supplements for the prevention and/or treatment of ovarian cysts. The supplements outlined here may play a role in minimizing symptoms and support- ing hormone balance and liver health. Calcium D-glucarate: Helps the liver detoxify and eliminate excess hormones, particularly estrogen. Chasteberry: Balances estrogen to progesterone ratio and may help normalize ovulation. Indole-3-carbinol: A compound found naturally in cruciferous vegetables that aids in de- toxification of estrogen, protects liver function, and may protect against hormonal cancers. Complementary Supplements Evening primrose oil: Helps reduce pain and inflammation. Some are harmless and even beneficial for health and others can cause illness and disease. A parasite is an organism that lives on or in a host organism and gets its food from or at the expense of its host. There are two main classes of parasites that can cause intestinal disease in humans: Helminths: Derived from the Greek word for “worms,” these large, multicellular organisms are generally visible to the naked eye. The three main groups of helminths that are human parasites are flatworms (tapeworms), P thorny-headed worms, and roundworms (hookworms and pinworms). Protozoa: Microscopic, one-celled organisms that can be free-living or parasitic in nature. They can multiply in humans, which contributes to their survival and also permits serious infections to develop from just a single organism. When the organisms are swallowed, they move into the intestine, where they can reproduce and cause disease. You can also contract parasites from intimate contact (oral-anal) with someone who has them. In some people, intestinal parasites do not cause any symptoms or the symptoms may be mild. In others they can cause horrible gastrointestinal problems, weight loss, irritability, and more. There are also a variety of lifestyle measures that can reduce your risk of contracting parasites. Fecal testing (exami- nation of your stool) can identify both helminths and protozoa. It is important to do stool tests before taking any anti-diarrheal drugs or antibiotics. Natural products, while helpful, are not as effective and take longer to work compared to prescription drugs. Dietary Recommendations Foods to include: • Boost intake of fibre, which helps improve elimination. Lifestyle Suggestions To reduce the risk of contracting parasites, consider these tips: • Wash your hands after using the toilet, changing diapers, handling animals, or before eat- ing or preparing food.

He fills out some Thought Trackers and zeroes in on a malicious thought: “I’ll never be happy again buy genuine cialis sublingual online impotence mayo. Chapter 6: Indicting and Rehabilitating Thoughts 85 Worksheet 6-9 Connor’s Thought on Trial Worksheet Accused thought: I’ll never be happy again — life will just be a downhill slide from here buy cialis sublingual overnight impotence 19 year old. Defending the Thought Prosecuting the Thought This hip replacement is just Many people get hip replacements without the beginning of the end buy cialis sublingual pills in toronto erectile dysfunction medication does not work. I get my greatest pleasure That’s hogwash — I do get pleasure from from the outdoors order cheapest cialis sublingual and cialis sublingual erectile dysfunction 26. If I can’t other things such as going to movies, reading do that anymore, I can’t novels, and going out to dinner. No one wants to be around That’s probably true if I act like a whining someone who’s sick and victim. I’m sure I’ll be confined to a That’s distorted logic; it’s using unreliable wheelchair soon. And even if it turned out to be the case, people in wheelchairs also can lead productive lives. Most likely, I’ll have some discomfort after the surgery, and it will take some time to get better. Good grief; one of the other teachers at school had a hip replacement last summer and he looks good as new. He now realizes the thought, “I’ll never be happy again — life will just be a downhill slide from here,” is far from the truth and certainly doesn’t help him cope with his reality. Emma: Filled with anxiety Emma, a 37-year-old loan officer, regularly puts in a 50-hour workweek. She worries about keeping up with her job and being a good mother to her two children. So when Emma’s son brings home a mediocre report card, she crashes into a terrible depres- sion. She loses her temper and screams at her son, and then she berates herself for being a terrible mother. Emma completes a Thought Tracker and then puts her most malicious thought on trial (see Worksheet 6-10). Worksheet 6-10 Emma’s Thought on Trial Worksheet Accused thought: I’m a complete failure as a mother; my son is falling apart. Defending the Thought Prosecuting the Thought My son is doing horrible in He had one bad report card. If I were a good mother, I I wonder why the teacher didn’t contact me would have known that he before report card time. I haven’t gone on a field trip Out of 30 kids, only a few parents were able to with my son’s class because drive on field trips. Other mothers even I wish I could spend more time with my son, but volunteer in the classroom. I have been putting my job That’s not really true; when my kids really need ahead of my children. Chapter 6: Indicting and Rehabilitating Thoughts 87 Defending the Thought Prosecuting the Thought I don’t know what to do to I guess I’ll do what the teacher suggests and help him. Thought Court is one of the most effective tools for combating anxiety, depression, and other unpleasant emotions. If you have trouble with the exercise, spend more time going over the Prosecutor’s Investigative Questions in Worksheet 6-3. It also doesn’t hurt to review Chapter 5 and re-read the examples in this chapter. If you still struggle, we recom- mend you consult a mental health professional who’s proficient in cognitive therapy. After the Verdict: Replacing and Rehabilitating Your Thoughts Hopefully, the prosecution presents a convincing case against a variety of your malicious thoughts, and you begin to see that many of your thoughts are guilty of scrambling reality and causing excessive emotional distress. When criminals are convicted, society usually tries to rehabilitate them and give them a second chance. In this section, we show you how to rehabilitate your guilty thoughts, one at a time. Rehabilitating your thoughts decreases feelings of depression and anxiety because rehabili- tated thoughts are less distorted, judgmental, and critical. We call rehabilitated thoughts replacement thoughts because they replace your old malicious thoughts. The reason for forming a single replacement thought is that you can use that new thought repeatedly when- ever the old, malicious thoughts start rumbling through your mind. The new thought is a quick and easy comeback to negative, distorted, reality-scrambled thinking. You can use a number of different techniques to develop effective replacement thoughts. The strategies outlined in the following sections help you discard distortions and straighten out your thinking. With these strategies, you discover how to replace your twisted thoughts with more helpful, realistic replacement thoughts. You start by imagining that a good friend of yours is going through the same kind of problem as you are. We don’t want you to simply try to make your friend feel better by sugarcoating the issue; rather, tell your friend about a reasonable way to think about the problem. The essence of this powerful, yet surprisingly simple, technique is that the advice you would give a friend is advice you can give to yourself. The following example shows you how to use Getting Help from a Friend to your advantage. Emma (see “Emma: Filled with anxiety” earlier in this chapter) has taken her most malicious thought to Thought Court and found it guilty. She imagines Louise coming to her with the same problem and concerns about her son. In other words, Louise is thinking Emma’s most malicious thought and seeking advice (see Worksheet 6-11). Emma’s/Louise’s most malicious thought: I’m a complete failure as a mother; my son is falling apart. Worksheet 6-11 Emma’s Getting Help from a Friend (Louise) Well, Louise, I know you feel like a failure, but your son only came home with two C’s and three B’s. Sure, you haven’t spent as much time with him lately, but you’ve been pretty tied up at work. Besides, your son is 16 now; don’t you think he has something to do with his own success and failure? She sees that her perspective changes when she gives Louise advice rather than listen to the negative automatic dialogue in her own head. Next, she distills this perspective into a single replacement thought (see Worksheet 6-12). Worksheet 6-12 Emma’s Replacement Thought My son isn’t falling apart and I’m not a failure. Chapter 6: Indicting and Rehabilitating Thoughts 89 Take one of your most malicious thoughts and use the Getting Help from a Friend strategy to devise an effective response to that thought. Of course, it helps to take the malicious thought to Thought Court first, which you’ve done — right? Write down one of your most malicious thoughts from your Thought Tracker (see Worksheet 6-6). Imagine that the friend has a problem very similar to your own and has similar thoughts about the problem. Imagine you’re talking with your friend about a better way to think about and deal with the problem. Look over that advice and try to rehabilitate your most malicious thought into a more balanced, summary replacement thought in Worksheet 6-14. My most malicious thought: __________________________________________________________________________________ Worksheet 6-13 My Getting Help from a Friend Worksheet 6-14 My Replacement Thought Traveling to the future The events that disrupt your life today rarely have the same meaning after a few days, weeks, or months. If you think back on these events after some time has passed, however, rarely can you muster up the same intensity of emotion. That’s because most upsetting events truly aren’t all that important if you look at them in the context of your entire life. Check out the following example of the Traveling to the Future technique in action. He’d like to sell the property, but he knows it’s worth far more if it can be zoned for commercial purposes first. In order to do that, Joel must present his case in front of the Zoning Commission. He expects some opposition and criticism from homeowners in the area, and he’s been putting this task off for months because of the intense anxiety it arouses in him. He fills out a Thought Tracker (see “From Arraignment to Conviction: Thought Court” ear- lier in this chapter) and identifies his most malicious thought: “I’ll make a fool out of myself. He rates the emotional upset and effect on his life that he feels right now, and then he re-rates the impact on his life at the conclusion of the exercise. Worksheet 6-15 Joel’s Traveling to the Future If I do indeed make a fool out of myself, I’ll probably feel pretty bad and the impact on my life will feel like 30 or even 40 on a 100-point scale. I suspect that images of the incident will go through my mind fairly often, but six months from now, I doubt I’ll think about the inci- dent much at all. So I guess the overall effect on my life will likely be about a 1 on a 100-point scale. After pondering what his malicious thought will seem like in the future, Joel feels ready to develop a more realistic replacement thought (see Worksheet 6-16). Chapter 6: Indicting and Rehabilitating Thoughts 91 Worksheet 6-16 Joel’s Replacement Thought Even if I should happen to make a fool out of myself, it’s hardly going to be a life-changing event. The Traveling to the Future technique won’t apply to all your thoughts and problems, but it works wonders with quite a few.

Sex as a risk and pregnancy avoidance A focus on sex for pleasure and an emphasis on sex as a risk has resulted in a literature on contraception use and pregnancy avoidance proven 20mg cialis sublingual erectile dysfunction treatment fort lauderdale. Psychologists have developed models in order to describe and predict this behaviour generic cialis sublingual 20mg on line erectile dysfunction treatment cialis. Researchers have used several different classifications of contraception in an attempt to predict contraceptive use purchase cialis sublingual canada erectile dysfunction drugs and medicare. In addition cheap cialis sublingual 20mg visa wellbutrin xl impotence, different measures of actual behaviour have been used when predicting contraception use: s at first ever intercourse; s at most recent intercourse; s at last serious intercourse; s at last casual intercourse. This produced a wealth of data about factors such as age of first intercourse, homosexuality, attitudes to sexual behaviours and contraception use. These results suggest that the younger someone is when they first have sex (either male or female), the less likely they are to use contraception. The results from this survey also show what kinds of contraception people use at first intercourse. The different measures of contraception use have implications for interpreting findings on contraception. Developmental models are more descriptive, whereas decision-making models examine the predictors and precursors to this behaviour. Developmental models Developmental models emphasize contraception use as involving a series of stages. Therefore, they describe the transition through the different stages but do not attempt to analyse the cognitions that may promote this transition. Lindemann’s three-stage theory Lindemann (1977) developed the three-stage theory of contraception use, which suggests that the likelihood of an individual using contraception increases as they progress through the three stages: 1 Natural stage: at this stage intercourse is relatively unplanned, and the individual does not regard themselves as sexual. It suggests that contraception use is more likely to occur at a stage when the individual believes that sexual activity is ‘right for them’. This process involves the following four stages: 1 Falling in love: this provides a rationale for sex. Decision-making models Decision-making models examine the psychological factors that predict and are the precursors to contraception use. There are several different decision-making models and they vary in their emphasis on individual cognitions (e. Rosenstock 1966; Becker and Rosenstock 1987) and is described in detail in Chapter 2. They added the following variables: s self-esteem; s interpersonal skills; s knowledge about sex and contraception; s attitudes to sex and contraception; s previous sexual, contraceptive and pregnancy experiences; s peer norms; s relationship status; and s substance use prior to sex. Therefore, although this model still examines cognitions, it includes measures of the individuals’ cognitions about their social world. The theory of reasoned action This theory was developed by Fishbein and Ajzen (1975) and is described in detail in Chapter 2. It therefore represents an attempt to add the social context to individual cognitive variables and consequently addresses the problem of interaction. In addition, research by Werner and Middlestadt (1979) reported correlations between attitudes to contraception and subjective norms and actual use of oral contraception. Sexual arousal refers to how aroused an individual is at the time of making a decision about contraception. Herold and McNamee’s (1982) model This model is made up of the following variables: (1) parental and peer group norms for acceptance of premarital intercourse; (2) number of lifetime sexual partners; (3) guilt about intercourse and attitudes to contraception; (4) involvement with current partner; (5) partner’s influence to use contraception; and (6) frequency of intercourse. This model differs from other models of contraception use as it includes details of the relation- ship. It places contraception use both within the general context of social norms and also within the context of the relationship. In summary These decision-making models regard contraceptive use as resulting from an analysis of the relevant variables. However, they vary in the extent to which they attempt to place the individual’s cognitive state within a broader context, both of the relationship and the social world. Integrating developmental and decision-making approaches to contraception use Developmental models emphasize behaviour and describe reliable contraception use as the end product of a transition through a series of stages. These models do not examine the psychological factors, which may speed up or delay this transition. In contrast, decision-making models emphasize an individual’s cognitions and, to a varying degree, place these cognitions within the context of the relationship and social norms. Perhaps these cognitions could be used to explain the behavioural stages described by the developmental models. They defined these factors as follows: Background factors 1 Age: evidence suggests that young women’s contraceptive use increases with age (e. Although these background factors may influence contraceptive use, whether this effect is direct or through the effect of other factors such as knowledge and attitudes is unclear. Intrapersonal factors 1 Knowledge: Whitley and Schofield (1986) analysed the results of 25 studies of contraceptive use and reported a correlation of 0. For example, Cvetkovich and Grote (1981) reported that of their sample 10 per cent did not believe that they could become pregnant the first time they had sex, and 52 per cent of men and 37 per cent of women could not identify the periods of highest risk in the menstrual cycle. In addition, Lowe and Radius (1982) reported that 40 per cent of their sample did not know how long sperm remained viable. Negative attitudes included beliefs that ‘it kills spontaneity’, ‘it’s too much trouble to use’ and that there are possible side effects. In addition, carrying contraceptives around is often believed to be associated with being promiscuous (e. This research assumes that certain aspects of individuals are consistent over time and research has reported associations between the following types of personality: s conservatism and sex role have been shown to be negatively related to contraceptive use (e. Interpersonal factors Research highlights a role for characteristics of the following significant others: 1 Partner: facets of the relationship may influence contraception use including duration of relationship, intimacy, type of relationship (e. They included interpersonal and situational factors as a means to place the individual’s cognitions within the context of the relationship and the broader social world. These variables can be applied individually or alternatively incorporated into models. In particular, social cognition models emphasize cognitions about the individual’s social world, particularly their normative beliefs. However, whether asking an individual about the relationship really accesses the interaction between two people is questionable. For example, is the belief that ‘I decided to go on the pill because I had talked it over with my partner’ a statement describing the interaction between two individuals, or is it one individual’s cognitions about that interaction? Although sometimes ignored, this research is also relevant to other sexually transmitted diseases. Since then, health education programmes have changed in their approach to preventing the spread of the virus. For example, early campaigns emphasized monogamy or at least cutting down on the number of sexual partners. Campaigns also promoted non- penetrative sex and suggested alternative ways to enjoy a sexual relationship. As a result, research has examined the prerequisites to safer sex and condom use in an attempt to develop successful health promotion campaigns. Richard and van der Pligt (1991) examined condom use among a group of Dutch teenagers and report that 50 per cent of those with multiple partners were consistent condom users. It reported that 16 per cent of these used condoms on their own, 13 per cent had used condoms while on the pill, 2 per cent had used condoms in combination with spermicide and 3 per cent had used condoms together with a diaphragm. Overall only 30 per cent of their sample had ever used condoms, while 70 per cent had not. Fife-Schaw and Breakwell (1992) undertook an overview of the literature on condom use among young people and found that between 24 per cent and 58 per cent of 16- to 24-year-olds had used a condom during their most recent sexual encounter. In terms of their condom use with their current partner, 25 per cent reported always using a condom with their current male partner, 12 per cent reported always using a condom with their current female partner, 27 per cent reported some- times/never using a condom with their male partner and 38 per cent reported some- times/never using a condom with their female partner. In terms of their non-current partner, 30 per cent had had unprotected sex with a man and 34 per cent had had unprotected sex with a woman. Bisexuals are believed to present a bridge between the homosexual and heterosexual populations and these data suggest that their frequency of condom use is low. They reported that over the one-year follow-up, condom use during vaginal intercourse with prostitutes/clients was high and remained high, condom use with private partners was low and remained low, but that both men and women reduced their number of sexual partners by 50 per cent. The results from the General Household Survey (1993) provided some further insights into changes in condom use in Britain from 1983 to 1991 (see Figure 8. These data indicate an overall increase in condom use as the usual form of contraception, which is particularly apparent in the younger age groups. However, since this time there has been an increase in rectal gonorrhoea and clinical experience, cross-sectional and longitudinal Fig. These data suggest that many individuals do report using condoms, although not always on a regular basis. Therefore, although the health promotion messages may be reaching many individuals, many others are not complying with their recommendations. Predicting condom use Simple models using knowledge only have been used to examine condom use. These models are similar to those used to predict other health-related behaviours, including contraceptive use for pregnancy avoidance, and illustrate varying attempts to understand cognitions in the context of the relationship and the broader social context. Rosenstock 1966; Becker and Rosenstock 1987) (see Chapter 2) and has been used to predict condom use. They reported that the components of the model were not good predictors and only perceived susceptibility was related to condom use. This suggests that condom use is a habitual behaviour and that placing current condom use into the context of time and habits may be the way to assess this behaviour. This presents the problem of a ceiling effect with only small differences in ratings of this variable. Abraham and Sheeran (1993) suggest that social skills may be better predictors of safe sex. These models address the problem of how beliefs are turned into action using the ‘behavioural intentions’ component.