Economic evaluations of clinical pharmacy services in Ireland, 2007-2015

Introduction The concept of this thesis was driven by stagnation within the Irish healthcare system. Multiple reports from pharmacy organisations had outlined possible future directions for the profession but progress was minimal, especially in comparison with other countries. The author’s directive was to evaluate the economic impact of a series of clinical pharmacy services (CPS) in hospital and community settings. Methods A systematic review of economic evaluations of clinical pharmacy services in hospital patients was undertaken to gain insight into recent research in the field. Eligible studies were evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS), to establish the quality, consistency and transparency of relevant research. A retrospective analysis of an internal hospital pharmacy interventions database was conducted. A method first described by Nesbit et al. was implemented to estimate the level of cost avoidance achieved. A cost-effectiveness analysis based on data from a randomised controlled trial of a pharmacist-supervised patient self-testing (PST) of warfarin therapy is presented. Outcome measure was the incremental cost associated with six months of intervention management. A similar cost-effectiveness analysis based on previously published RCT data was used to evaluate a novel structured pharmacist review of medication in older hospitalised patients. Cost-effectiveness analysis was presented in the form of an incremental cost-effectiveness ratio (ICER). An ICER is an additional cost per unit effect, in the case of this study, the cost of preventing an additional non-trivial ADR in hospital. A method described by Preaud et al. was adapted to estimate the clinical and economic benefit gained from vaccination of patients by a community pharmacist in Ireland in 2013/14. Sample demographic data was obtained from a national chain of community pharmacies and applied to overall national vaccination data. Results Systematic review identified twenty studies which were eligible for inclusion. Overall, pharmacist interventions had a positive impact on hospital budgets. Only three studies (15%) were deemed to be “good-quality” studies. No ‘novel’ clinical pharmacist intervention was identified during the course of this review. Analysis of internal hospital database identified 4,257 interventions documented on 2,147 individual patients over a 12 month period. Substantial cost avoidance of €710,000 was generated over a 1 year period from the perspective of the health care provider. Mean cost avoidance of €166 per intervention was generated. The cost of providing these interventions was €82,000. Substantial net cost-benefits of €626,279 and a cost-benefit ratio of 8.64 : 1 were generated based on this evaluation of pharmacist interventions. Results from an evaluation of a novel pharmacist-led form of warfarin management indicated indicated that on a per patient basis, PST was slightly more expensive than established anticoagulant management. On a per patient basis over a six month period, PST resulted in an incremental cost of €59.08 in comparison with routine care. Overall cost of managing a patient through pharmacist-supervised PST for a six month period is €226.45. However, for this increase in cost a clinically significant improvement in care was provided. Patients achieved a significantly higher time in therapeutic range during the PST arm in comparison with routine care, (72 ± 19.7% vs 59 ± 13.5%). Difference in overall cost was minimal and PST was the dominant strategy in some scenarios examined during sensitivity analysis. Structured pharmacist review of medication was determined to be dominant in comparison to usual pharmaceutical care. Even if the healthcare payer was unwilling to pay any money for the prevention of an ADR, the intervention strategy is still likely to be cost-effective (probability of being determined cost-effective = 0.707). Implementation of pharmacist-led influenza vaccination has resulted in substantial clinical and economic benefits to the healthcare system. The majority of patients (64.9%) who availed of this service had identifiable influenza-related risk factors. Of patients with influenza-related risk factors, age ≥65 year was the most commonly cited risk factor. Pharmacist vaccination services averted a total of 848 influenza cases across all age groups during the 2013/2014 influenza season. Due to receipt of vaccination in a pharmacy setting, 444 influenza-related GP visits were prevented. In terms of more serious influenza-associated events, 11 hospitalisations and five influenza-related deaths were averted. Costs averted were approximately €305,000. These were principally wider societal-related costs associated with lost productivity. Conclusion Overall, clinical pharmacy services are adding value to the Irish healthcare system in both hospital and community settings, but provision of additional funding for new services would enable them to offer a great deal more.

Structured professional judgement approach to risk assessment: generalisability across patient groups for the prediction of adverse outcomes in secure mental health care

This is a redacted version of the the final thesis. Copyright material has been removed to comply with UK Copyright Law.

Emergy analysis of a silvo-pastoral system, a case study in southern Portugal

The Mediterranean silvo-pastoral system known as Montado, in Portugal, is a complex land use system composed of an open tree stratum in various densities and an herbaceous layer, used for livestock grazing. Livestock also profit from the acorns, and the grazing contributes to avoid shrub encroachment. In the last 20 years, subsidies from the European Union have greatly promoted cattle rearing in this system and the introduction of heavy breeds, at the expense of sheep, goats or the native cattle breeds. The balance of the traditional system is thus threatened, and a precise assessment of the balance between the different components of the system, therefore is highly needed. The goal of this study was to gain a better under- standing of a Montado farm system with cattle rearing as the major economic activity by applying the emergy evaluation method to calculate indices of yield, investment, environmental loading and sustainability. By integrating different ecosystem components, the emergy evaluation method allows a comprehensive evaluation of this complex and multifunctional system at the scale of an individual farm. This method provides a set of indices that can help us understand the system and design management strategies that maximize emergy flow in the farm. In this paper, we apply the emergy evaluation method to a Montado farm with cattle rearing, as a way to gain a better understanding of this system at the farm scale. The value for the transformity of veal (2.66E?06 sej J-1) is slightly higher, when compared to other systems producing protein. That means that the investment of nature and man in this product was higher and it requires a premium price on the market. The renewa- bility for Holm Oaks Farm (49 %), lower than for other similar systems, supports the assumption that this is a farm in which, comparing with others, the number of purchased inputs in relation to renewable inputs provided by nature, is higher. The Emergy Investment Ratio is 0.91 for cattle rearing compared to a value of 0.49 for cork and 0.43 for firewood harvesting, making it clear that cattle rearing is a more labor demanding activity comparing with extractive activities as cork and firewood harvesting.

Innovative Al Alloys for High Performance Automotive Pistons: Enhancement of Specific Strength at High Temperature and Resistance to Knock Damage

The increasingly strict regulations on greenhouse gas emissions make the fuel economy a pressing factor for automotive manufacturers. Lightweighting and engine downsizing are two strategies pursued to achieve the target. In this context, materials play a key role since these limit the engine efficiency and components weight, due to their acceptable thermo-mechanical loads. Piston is one of the most stressed engine components and it is traditionally made of Al alloys, whose weakness is to maintain adequate mechanical properties at high temperature due to overaging and softening. The enhancement in strength-to-weight ratio at high temperature of Al alloys had been investigated through two approaches: increase of strength at high temperature or reduction of the alloy density. Several conventional and high performance Al-Si and Al-Cu alloys have been characterized from a microstructural and mechanical point of view, investigating the effects of chemical composition, addition of transition elements and heat treatment optimization, in the specific temperature range for pistons operations. Among the Al-Cu alloys, the research outlines the potentialities of two innovative Al-Cu-Li(-Ag) alloys, typically adopted for structural aerospace components. Moreover, due to the increased probability of abnormal combustions in high performance spark-ignition engines, the second part of the dissertation deals with the study of knocking damages on Al pistons. Thanks to the cooperation with Ferrari S.p.A. and Fluid Machinery Research Group - Unibo, several bench tests have been carried out under controlled knocking conditions. Knocking damage mechanisms were investigated through failure analyses techniques, starting from visual analysis up to detailed SEM investigations. These activities allowed to relate piston knocking damage to engine parameters, with the final aim to develop an on-board knocking controller able to increase engine efficiency, without compromising engine functionality. Finally, attempts have been made to quantify the knock-induced damages, to provide a numerical relation with engine working conditions.

Cadmium Telluride Magic-Sized Clusters and Superstructures

The aim of the present work is to gain new insights into the formation mechanism of CdTe magic-sized clusters (MSCs) at low temperatures, as well as on their evolution towards 1D and 2D nanostructures and assemblies thereof, under mild reaction conditions. The reaction system included toluene as solvent, octylamine as primary alkylamine, trioctylphosphine-Te as chalcogenide precursor and Cd(oleate)2 as metal precursor. UV-Vis absorption spectroscopy and transmission electron microscopy (TEM) were used to analyze samples containing concentrations of octylamine of 0.2, 0.8 and 2 M: well-defined, sharp absorption peaks were observed, with peaks maxima at 449, 417 and 373 nm respectively, and 1D structures with a string-like appearance were displayed in the TEM images. Investigating peaks growth, step-wise peaks shift to lower energies and reverse, step-wise peak shift to higher energies allowed to propose a model to describe the system, based on interconnected [CdTe]x cluster units originating an amine-capped, 1-dimensional, polymer-like structure, in which different degrees of electronic coupling between the clusters are held responsible for the different absorption transitions. The many parameters involved in the synthesis procedure were then investigated, starting from the Cd:Te ratio, the role of the amine, the use of different phosphine-Te and Cd precursors. The results allowed to gain important information of the reaction mechanism, as well as on the different behavior of the species featuring the sharp absorption peaks in each case. Using Cd(acetate)2 as metal precursor, 2D structures were found to evolve from the MSCs solutions over time, and their tendency to self-assemble was then analyzed employing two amines of different alkyl chain length, octylamine (C-8) and oleylamine (C-18). Their co-presence led to the formation of free-floating triangular nanosheets, which tend to readily aggregate if only octylamine is present in solution.

Design and testing of innovative, artificial intelligence-based techniques to model and control the combustion process and to reduce the Co2 emissions in modern, high-performance, gasoline direct injection engines

This work deals with the development of calibration procedures and control systems to improve the performance and efficiency of modern spark ignition turbocharged engines. The algorithms developed are used to optimize and manage the spark advance and the air-to-fuel ratio to control the knock and the exhaust gas temperature at the turbine inlet. The described work falls within the activity that the research group started in the previous years with the industrial partner Ferrari S.p.a. . The first chapter deals with the development of a control-oriented engine simulator based on a neural network approach, with which the main combustion indexes can be simulated. The second chapter deals with the development of a procedure to calibrate offline the spark advance and the air-to-fuel ratio to run the engine under knock-limited conditions and with the maximum admissible exhaust gas temperature at the turbine inlet. This procedure is then converted into a model-based control system and validated with a Software in the Loop approach using the engine simulator developed in the first chapter. Finally, it is implemented in a rapid control prototyping hardware to manage the combustion in steady-state and transient operating conditions at the test bench. The third chapter deals with the study of an innovative and cheap sensor for the in-cylinder pressure measurement, which is a piezoelectric washer that can be installed between the spark plug and the engine head. The signal generated by this kind of sensor is studied, developing a specific algorithm to adjust the value of the knock index in real-time. Finally, with the engine simulator developed in the first chapter, it is demonstrated that the innovative sensor can be coupled with the control system described in the second chapter and that the performance obtained could be the same reachable with the standard in-cylinder pressure sensors.

Growth performance, gut health, and metabolism of broilers under thermoneutral and heat stress conditions: multidisciplinary studies on the effects of nutritional strategies and genotype

This PhD project aimed to (i) investigate the effects of three nutritional strategies (supplementation of a synbiotic, a muramidase, or arginine) on growth performance, gut health, and metabolism of broilers fed without antibiotics under thermoneutral and heat stress conditions and to (ii) explore the impacts of heat stress on hypothalamic regulation of feed intake in three broiler lines from diverse stages of genetic selection and in the red jungle fowl, the ancestor of domestic chickens. Synbiotic improved feed efficiency and footpad health, increased Firmicutes and reduced Bacteroidetes in the ceca of birds kept in thermoneutral conditions, while did not mitigate the impacts of heat stress on growth performance. Under optimal thermal conditions, muramidase increased final body weight and reduced cumulative feed intake and feed conversion ratio in a dose-dependent way. The highest dose reduced the risk of footpad lesions, cecal alpha diversity, the Firmicutes to Bacteroidetes ratio, and butyrate producers, increased Bacteroidaceae and Lactobacillaceae, plasmatic levels of bioenergetic metabolites, and reduced the levels of pro-oxidant metabolites. The same dose, however, failed to reduce the effects of heat stress on growth performance. Arginine supplementation improved growth rate, final body weight, and feed efficiency, increased plasmatic levels of arginine and creatine and hepatic levels of creatine and essential amino acids, reduced alpha diversity, Firmicutes, and Proteobacteria (especially Escherichia coli), and increased Bacteroidetes and Lactobacillus salivarius in the ceca of thermoneutral birds. No arginine-mediated attenuation of heat stress was found. Heat stress altered protein metabolism and caused the accumulation of antioxidant and protective molecules in oxidative stress-sensitive tissues. Arginine supplementation, however, may have partially counterbalanced the effects of heat stress on energy homeostasis. Stable gene expression of (an)orexigenic neuropeptides was found in the four chicken populations studied, but responses to hypoxia and heat stress appeared to be related to feed intake regulation.

Metabolomics to investigate the effects of treatments on food and of food consumption on health

Metabolomics has established itself as a discipline that can offer a unique point of view on how a technological treatment could impact on the charactersitics of a food. Even more, the same analytical platforms necessary for the purpose can also effectively unravel intricate interactions between such food and human health upon consumption. This PhD thesis investigates the application of metabolomics in understanding the impact of technological treatments on food and their subsequent effects on human health, utilizing 1H-NMR as the analytical platform. The study involves the development of standard operating procedures (SOPs) to ensure a fast and stable preparation of seafood samples, incorporating novel algorithms to enhance the accuracy of metabolome profiles. To gain insight on how metabolomics can allow exploring the effects of a technological treatment on a food, we performed three sets of experiments to investigate the application of metabolomics in studying the impact of high hydrostatic pressure (HHP) treatment on seafood metabolome during storage. The first experiment employs untargeted metabolomic analysis on chill-stored rose shrimp, revealing significant post-HHP treatment metabolic alterations and mechanisms. The investigation is extended to grey mullet in the second experiment, utilizing both untargeted and targeted metabolomic analyses to account for matrix-related effects. The third experiment assesses the targeted metabolome of striped prawns, showing that HHP significantly influences metabolic pathways, positively impacting freshness and taste through alterations in related metabolites. Shifting focus to the effects of food on humans, the study explores the impact of multistrain probiotics on cirrhosis patients using 1H-NMR. The platform reveals notable alterations in glutamine/glutamate metabolism, enhancing the patients' ammonia detoxification capacity. This research underscores the potential of metabolomics in uncovering intricate interactions between technological treatments, food, and human health, providing valuable insights for both the food industry and healthcare interventions.

Debonding and crack propagation in cracked steel beams strengthened with CFRP and subjected to cyclic loads.

The reinforcement methods used to restore or increase the bearing capacity of metal structures are based on the application of steel plates to be bolted or welded to the original structure, which can cause problems to the integrity of the original structure. These difficulties can be overcome with the introduction of fiber-reinforced composite materials. FRPs are characterized by high strength to weight ratio, and they are very resistant to corrosion. In this dissertation a cracked steel I-beam reinforced with Carbon Fiber-Reinforced Polymer will be studied by performing a numerical evaluation of the structure with the commercial Finite Element Method software ABAQUS. The crack propagation will be computed using XFEM, while the debonding of the reinforcement layer will be found by considering a cohesive contact interface between the beam and the CFRP plate. The results will show the efficiency of the strengthening method in increasing the load carrying capacity of the cracked beam, and in reducing the crack opening of the initial notch.

Phylogenetic Analysis Of The Microbial Community In Hypersaline Petroleum Produced Water From The Campos Basin.

In this work the archaea and eubacteria community of a hypersaline produced water from the Campos Basin that had been transported and discharged to an onshore storage facility was evaluated by 16S recombinant RNA (rRNA) gene sequence analysis. The produced water had a hypersaline salt content of 10 (w/v), had a carbon oxygen demand (COD) of 4,300 mg/l and contains phenol and other aromatic compounds. The high salt and COD content and the presence of toxic phenolic compounds present a problem for conventional discharge to open seawater. In previous studies, we demonstrated that the COD and phenolic content could be largely removed under aerobic conditions, without dilution, by either addition of phenol degrading Haloarchaea or the addition of nutrients alone. In this study our goal was to characterize the microbial community to gain further insight into the persistence of reservoir community members in the produced water and the potential for bioremediation of COD and toxic contaminants. Members of the archaea community were consistent with previously identified communities from mesothermic reservoirs. All identified archaea were located within the phylum Euryarchaeota, with 98 % being identified as methanogens while 2 % could not be affiliated with any known genus. Of the identified archaea, 37 % were identified as members of the strictly carbon-dioxide-reducing genus Methanoplanus and 59 % as members of the acetoclastic genus Methanosaeta. No Haloarchaea were detected, consistent with the need to add these organisms for COD and aromatic removal. Marinobacter and Halomonas dominated the eubacterial community. The presence of these genera is consistent with the ability to stimulate COD and aromatic removal with nutrient addition. In addition, anaerobic members of the phyla Thermotogae, Firmicutes, and unclassified eubacteria were identified and may represent reservoir organisms associated with the conversion hydrocarbons to methane.

Growth And Body Composition In Brazilian Female Rhythmic Gymnastics Athletes.

The aim was to analyse the physical growth and body composition of rhythmic gymnastics athletes relative to their level of somatic maturation. This was a cross-sectional study of 136 athletes on 23 teams from Brazil. Mass, standing height and sitting height were measured. Fat-free and fat masses, body fat percentages and ages of the predicted peak height velocity (PHV) were calculated. The z scores for mass were negative during all ages according to both WHO and Brazilian references, and that for standing height were also negative for all ages according to WHO reference but only until 12 years old according to Brazilian reference. The mean age of the predicted PHV was 12.1 years. The mean mass, standing and sitting heights, body fat percentage, fat-free mass and fat mass increased significantly until 4 to 5 years after the age of the PHV. Menarche was reached in only 26% of these athletes and mean age was 13.2 years. The mass was below the national reference standards, and the standing height was below only for the international reference, but they also had late recovery of mass and standing height during puberty. In conclusion, these athletes had a potential to gain mass and standing height several years after PHV, indicating late maturation.

Membrane Lipid Profile Monitored By Mass Spectrometry Detected Differences Between Fresh And Vitrified In Vitro-produced Bovine Embryos.

Summary This study aimed to evaluate the impact of vitrification on membrane lipid profile obtained by mass spectrometry (MS) of in vitro-produced bovine embryos. Matrix-assisted laser desorption ionization-mass spectrometry (MALDI-MS) has been used to obtain individual embryo membrane lipid profiles. Due to conditions of analysis, mainly membrane lipids, most favorably phosphatidylcholines (PCs) and sphingomyelins (SMs) have been detected. The following ions described by their mass-to-charge ratio (m/z) and respective attribution presented increased relative abundance (1.2-20×) in the vitrified group: 703.5 [SM (16:0) + H]+; 722.5 [PC (40:3) + Na]+; 758.5 [PC (34:2) + H]+; 762.5 [PC (34:0) + H]+; 790.5 [PC (36:0) + H]+ and 810.5 [PC (38:4) + H]+ and/or [PC (36:1) + Na]+. The ion with a m/z 744.5 [PCp (34:1) and/or PCe (34:2)] was 3.4-fold more abundant in the fresh group. Interestingly, ions with m/z 722.5 or 744.5 indicate the presence of lipid species, which are more resistant to enzymatic degradation as they contain fatty acyl residues linked through ether type bonds (alkyl ether or plasmalogens, indicated by the lowercase 'e' and 'p', respectively) to the glycerol structure. The results indicate that cryopreservation impacts the membrane lipid profile, and that these alterations can be properly monitored by MALDI-MS. Membrane lipids can therefore be evaluated by MALDI-MS to monitor the effect of cryopreservation on membrane lipids, and to investigate changes in lipid profile that may reflect the metabolic response to the cryopreservation stress or changes in the environmental conditions.

Oligomerization, Membrane Association, And In Vivo Phosphorylation Of Sugarcane Udp-glucose Pyrophosphorylase.

Sugarcane is a monocot plant that accumulates sucrose to levels of up to 50% of dry weight in the stalk. The mechanisms that are involved in sucrose accumulation in sugarcane are not well understood, and little is known with regard to factors that control the extent of sucrose storage in the stalks. UDP-glucose pyrophosphorylase (UGPase; EC 2.7.7.9) is an enzyme that produces UDP-glucose, a key precursor for sucrose metabolism and cell wall biosynthesis. The objective of this work was to gain insights into the ScUGPase-1 expression pattern and regulatory mechanisms that control protein activity. ScUGPase-1 expression was negatively correlated with the sucrose content in the internodes during development, and only slight differences in the expression patterns were observed between two cultivars that differ in sucrose content. The intracellular localization of ScUGPase-1 indicated partial membrane association of this soluble protein in both the leaves and internodes. Using a phospho-specific antibody, we observed that ScUGPase-1 was phosphorylated in vivo at the Ser-419 site in the soluble and membrane fractions from the leaves but not from the internodes. The purified recombinant enzyme was kinetically characterized in the direction of UDP-glucose formation, and the enzyme activity was affected by redox modification. Preincubation with H2O2 strongly inhibited this activity, which could be reversed by DTT. Small angle x-ray scattering analysis indicated that the dimer interface is located at the C terminus and provided the first structural model of the dimer of sugarcane UGPase in solution.

The Neuromuscular Activity Of Bothriopsis Bilineata Smaragdina (forest Viper) Venom And Its Toxin Bbil-tx (asp49 Phospholipase A2) On Isolated Mouse Nerve-muscle Preparations.

The presynaptic action of Bothriopsis bilineata smaragdina (forest viper) venom and Bbil-TX, an Asp49 PLA2 from this venom, was examined in detail in mouse phrenic nerve-muscle (PND) preparations in vitro and in a neuroblastoma cell line (SK-N-SH) in order to gain a better insight into the mechanism of action of the venom and associated Asp49 PLA2. In low Ca(2+) solution, venom (3μg/ml) caused a quadriphasic response in PND twitch height whilst at 10μg/ml the venom additionally induced an abrupt and marked initial contracture followed by neuromuscular facilitation, rhythmic oscillations of nerve-evoked twitches, alterations in baseline and progressive blockade. The venom slowed the relaxation phase of muscle twitches. In low Ca(2+), Bbil-TX [210nM (3μg/ml)] caused a progressive increase in PND twitch amplitude but no change in the decay time constant. Venom (10μg/ml) and Bbil-TX (210nM) caused minor changes in the compound action potential (CAP) amplitude recorded from sciatic nerve preparations, with no significant effect on rise time and latency; tetrodotoxin (3.1nM) blocked the CAP at the end of the experiments. In mouse triangularis sterni nerve-muscle (TSn-m) preparations, venom (10μg/ml) and Bbil-TX (210nM) significantly reduced the perineural waveform associated with the outward K(+) current while the amplitude of the inward Na(+) current was not significantly affected. Bbil-TX (210nM) caused a progressive increase in the quantal content of TSn-m preparations maintained in low Ca(2+) solution. Venom (3μg/ml) and toxin (210nM) increased the calcium fluorescence in SK-N-SH neuroblastoma cells loaded with Fluo3 AM and maintained in low or normal Ca(2+) solution. In normal Ca(2+), the increase in fluorescence amplitude was accompanied by irregular and frequent calcium transients. In TSn-m preparations loaded with Fluo4 AM, venom (10μg/ml) caused an immediate increase in intracellular Ca(2+) followed by oscillations in fluorescence and muscle contracture; Bbil-TX did not change the calcium fluorescence in TSn-m preparations. Immunohistochemical analysis of toxin-treated PND preparations revealed labeling of junctional ACh receptors but a loss of the presynaptic proteins synaptophysin and SNAP25. Together, these data confirm the presynaptic action of Bbil-TX and show that it involves modulation of K(+) channel activity and presynaptic protein expression.

High Prevalence Of Insulin Resistance Assessed By The Glucose Clamp Technique In Hormonal And Non-hormonal Contraceptive Users.

Objective To assess the prevalence of insulin resistance (IR) and associated factors in contraceptive users. Methods A total of 47 women 18 to 40 years of age with a body mass index (kg/m(2)) < 30, fasting glucose levels < 100 mg/dl and 2-hour glucose level < 140 mg/dl after a 75-g oral glucose load were submitted to a hyperinsulinemic-euglycemic clamp. The women were distributed in tertiles regarding M-values. The analysed variables were use of combined hormonal/non-hormonal contraception, duration of use, body composition, lipid profile, glucose levels and blood pressure. Results IR was detected in 19% of the participants. The women with low M-values presented significantly higher body fat mass, waist-to-hip ratio, fasting insulin, HOMA-IR and were nulligravida, showed > 1 year of contraceptive use and higher triglyceride levels. IR was more frequent among combined oral contraceptive users, however no association was observed after regression analysis. Conclusions The prevalence of IR was high among healthy women attending a family planning clinic independent of the contraceptive method used with possible long-term negative consequences regarding their metabolic and cardiovascular health. Although an association between hormonal contraception and IR could not be found this needs further research. Family planning professionals should be proactive counselling healthy women about the importance of healthy habits.