Hrev_master Healthcare in Low-resource Settings 2025; volume 13:13478 Modeling correlates of long-acting contraceptive use in North West Ethiopia: a community based cross-sectional study Kebadu Tadesse Cherie,1 Gedif Mulat Alemayehu,2 Endalew Tesfa Getie1 1Department of Statistics, College of Natural & Computational Sciences, Debre Markos University, Debre Markos; 2Department of Statistics, College of Natural & Computational Science, Injibara University, Injibara, Ethiopia Abstract The use of long acting contraceptive methods is a common practice among women seeking to prevent unintended pregnancies and plan their families. This study seeks to identify factors associ- ated with the practice of long-acting contraceptive methods, par- ticularly in a conflict-affected area in Awi zone, North West Ethiopia. A cross-sectional study was conducted on a multistage random sample of 1,334 women’s. Bivariable and multivariable binary logistic regression has been applied to identify determinant factors. Among the 1,334 women surveyed, 25.49% reported using long-acting contraceptive methods. The analysis revealed that women’s educational level, wealth index, being visited by health extension, marital status, use of children as a source of income, and occupational status of women were factors signifi- cantly hindering the use of long-acting contraceptive methods in the area. In conclusion, higher contraceptive use was observed among educated, married women, women who used children as a source of income, and women employed by the government. It is therefore recommended that government officials in Awi Zone and policy makers should implement programs to increase female edu- cation and employment, which could lead to greater use of contra- ceptive methods for effective family planning. Introduction The rapid growth of the world population has become an urgent global concern. Most of this growth is occurring in devel- oping countries where, the fertility rate is very high.1 In most developing continents generally, and in sub-Sahara Africa partic- ularly, the problem of population growth and reproductive health challenges like high maternal mortality, high population growth rate, total fertility rate and much unmet need for family planning is increased.2,3 Ethiopia, like most countries in sub-Saharan Africa, is characterized by high fertility and rapid population growth. The country stands third next to Nigeria and Egypt in this respect.4 According to 2016 Ethiopian Demographic and Health Survey (EDHS) reports, from sexually active unmarried women, 58% were currently using a contraceptive method where 55% are using a modern method and 3% are using a traditional method. The higher fertility rate is associated with rapid population growth which directly associated with depletion of productive resources in the society, rising cost of commodity, poor nutrition and limited educational opportunities, and ultimately trapping women in a poverty cycle. High fertility increases health risks for children and mother, and also aggravates environmental threats.5 Thus, family planning contributes to promote the health and wel- fare of the family. It is the means of social development of a coun- try and the best way to control the rapidly and massively growing population which is also essential to the well-being of women, men, adolescents, and the community at large. Contraceptive offers the opportunity for women to plan and space pregnancies in order to achieve personal goals and self-sufficiency.6 Recently, women are desired to have more children in Awi Zone of North West Ethiopia which intends the population to increase time to time. In spite of the fact that family planning ser- Correspondence: Kebadu Tadesse Cherie, Department of Statistics, College of Natural & Computational Sciences, Debre Markos University, Debre Markos, P.O.Box: 269, Ethiopia. E-mail: kebadu.tadesse@dmu.edu.et Key words: Awi Zone, contraceptive methods, family planning, multiple logistic regression, Ethiopia. Authors’ contributions: KTC designed the study, performed the statistical analysis, and prepared the manuscript. GMA, designed the study, per- formed the statistical analysis and revised the manuscript. GMA collect- ed the data and interpreted the results. Both authors approved the final manuscript for publication. Funding: the author did not receive external fund for this research. Availability of data and materials: the dataset used in this study is avail- able upon request from the corresponding author. Ethical approval and consent to participate: informed consent to partici- pate was obtained both verbally and in writing, as the study involved both written and verbal questionnaires administered to women. Verbal consent was obtained from each participant, who was fully informed about the study's objectives and confidentiality of their responses were assured. The survey was initiated after receiving approval from the Amhara Public Health Institute Research Ethics Review Committee and the Awi Zone Health Office. Ethical clearance and consent to participate were granted by the committee. Consent for publication: not applicable. Conflict of interest: the authors declare that there is no any competing interest. Acknowledgments: the author has special gratitude for all the study par- ticipants and Woreda health office for their valuable information to accomplish this study. Finally we would like to thank data collectors who are supporting us by collecting basic in-formation from respondents even in difficult area of Awi zone, North West Ethiopia. Received: 18 December 2024. Accepted: 22 May 2025. Early access: 12 June 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 13:13478 doi:10.4081/hls.2025.13478 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2025;13:13478] [page 165] vice delivery facilities and other supplies have increased in number in the region particularly in Awi zone, the use of contraceptive methods are still low and as a result major portion of the popula- tion is still living in abject poverty.7 Most studies in developing countries, including Ethiopia, have put emphasis on the role of socio-economic, demographic and cul- tural factors in determining family planning. Thus, this study was intended to identify determinant factors of using long-acting fami- ly planning methods in a resource limited and conflict affected area in Awi zone, North West Ethiopia. Materials and Methods Study design A cross-sectional study was carried out among 1,334 reproduc- tive women between September 2022 and May 2023 in the Awi Zone, located in the Amhara region of North West Ethiopia. The area, characterized by its flat territory and fertile soil, has elevations ranging from 1,800 to 3,100 meters above sea level, with an aver- age altitude of approximately 2,300 meters. The zone comprises 215,564 households, with an average household size of 7 people. Sample size and sampling techniques The sample size was determined using sample size for percent- ages or proportions formula(8). Using 95% Confidence Level (CL), 3% margin of error (d) and 50 % proportion (p) of using fam- ily planning, the sample size was estimated as By considering 1.25 design effects the final sample size was 1,334. A multi-stage cluster sampling method with stratification was applied. In the first stage, two out of three administrative towns and five out of nine districts was selected through simple random sampling technique. In the second stage, two kebeles from Injibara town administration, two kebeles from Chagni town administration, three kebeles from Guagusa Shikudad district, three kebeles from Banja district, three kebeles from Ayehu Guagusa district, three kebeles from Dangla district and three kebeles from Jawi districts were selected randomly. In the third stage, a total of 1,334 households was selected using proportional allocation to each selected kebeles systematically and only one eli- gible mother was interviewed per household. All fertile women in the reproductive age of the household were included in the study, and if there were more than two moth- ers in the household, only one mother was selected randomly. Data collection tools and procedures Administered structured questioners were used to collect data. The questions were prepared including socio demographic and maternal contraceptive related factors through reviewing different literatures. The questioners first prepared in English language, and translated to Amharic and Awigna. Each questionnaire was checked for completeness of the information by the principal investigator. About 30 health extension workers were recruited as data collectors. Data quality control A pre-test of the questionnaire was conducted with 5% of the sample women within the study area and we assesses that, the questionnaire’s content adequately covers the concept it aims to measure. Based on the results of the pre-test, the questionnaire was revised and modified accordingly. Data collectors and supervisors underwent two days of training, facilitated by the investigators, prior to the actual data collection. The data’s consistency and com- pleteness were verified before any data entry or coding was attempted. Epi-Info version 7 was utilized to control and manage errors during the data entry process. Data processing and analysis The data were cleaned and entered into Epi-Info version 7, after which it was exported to STATA version 16 for analysis. Variables were recoded and computed as necessary for the analy- sis. We employed complete case analysis, which involves exclud- ing any observations with missing values as a method for handling missing data. A bivariate and multivariable logistic regression model was applied to identify factors associated with the use of contraceptive methods. To account for potential confounding vari- ables in the relationship between risk factors and long-acting con- traceptive use among women, we applied a statistical control method. Initially, binary logistic regression was used, including key confounders as covariates in the model, such as women age, women education, current marital status, maternal education and women occupation. Model adequacy checking was done using Hosmer and Lemshow test statistics. All explanatory variables with a p<0.25 from the bivariate analysis were included in the mul- tivariable analysis to control for potential confounding effects and associations were declared at 0.05 level of significance. The final model was selected using a backwards elimination approach, which started with a full model including all potential predictors and iteratively removed the least statistically significant variable, based on the Wald statistic, until all remaining variables were sta- tistically significant at a p-value of < 0.05. Results Socio demographic and economic characteristics As indicated in Table 1, among the 1,334 women sampled in Awi Zone, 25.49% reported using long-acting contraceptive meth- ods, while 74.51% did not. The use of long-acting contraceptives varied across different age groups of reproductive women. The highest usage rate (77.5%) was observed in women aged 35-44, while the lowest rate (68.9%) was seen in the 15-24 women’s age. A chi square test exhibited a significant association between women’s age and the use of long-acting contraceptives methods (X2: 7.208, p=0.027). Additionally, the highest proportion of women using long-acting contraceptives were those with no for- mal education (79.35%), followed by those who completed prima- ry school (66.7%) and those who finished secondary school or higher (53.9%). A chi square test showed a significant association between women’s educational level and the use of long-acting con- traceptives methods (X2: 41.288; p£0.001). As shown in Table 1, the use of long-acting contraceptive methods varied between women who had received family planning information through media and those who had not. Among the total sample, 77.2% of women who had not heard family planning infor- mation on the radio in the past month used long-acting contracep- Article [page 166] [Healthcare in Low-resource Settings 2025;13:13478] tive methods, while 66.8% of those who had heard family planning information on the radio used these methods. A chi square test showed a significant association between hearing about family planning in radio and the use of long-acting contraceptives meth- ods (X2:25.018; p≤0.001). The uses of long-acting contraceptive methods were also var- ied across marital status. Hence among single, married, divorced, and widwed women the usage rates were 86.7%, 71.9%, 98.6%, and 88.8%, respectively, with divorced women exhibiting the high- est rate of contraceptive use. Because divorced women desire to avoid the stress of an unintended pregnancy. The chi square test revealed a significant association between women’s marital status and the use of long-acting contraceptives methods (X2: 35.937; p£0.001). Additionally, 68.3% of women who relied on their chil- dren as a source of income reported using long-acting contracep- tives. Regarding women occupation, 70.8% of unemployed women, 75% of government-employed women, and 86.2% of housewives reported using contraceptive methods. Furthermore, the chi-square test of association showed that wealth index (X2: 80.330; p≤0.001), being visited by health extension (X2:17.233; p≤0.001), use of children as a source of income (X2:16.012; p≤0.001) and occupation (X2:17.074; p≤0.001) of women’s were significantly associated with use of long-acting contraceptive methods in Awi zone, North West Ethiopia. The results of detailed descriptive statistics including the crosstab and chi-square test of association are depicted in Table 1. Factors causing for usage of long-acting contra- ceptive methods Bivariate logistic regression analysis was employed for all independent variables to identify possible covariates for the multi- variable binary logistic regression. Age in 5-year Current marital status, heard family planning on radio, Women’s education, Wealth Index, Use child as source of income, being visited by health extension and women’s Occupation were found to be the candidate variables for the multivariable binary logistic regression analysis. The final multivariable binary logistic regression analyses were done to look the effects of the selected explanatory variables on the use of long-acting contraceptive. As it is shown in Table 2, the variables women’s educational level, wealth index, marital sta- tus, usage of children as source of income and women’s occupation were found significant factors on use of log acting contraceptive methods. The odds of women whose educational level was illiterate were 0.512 (AOR: 0.512, 95%CI: 0.298, 0.879, p=0.0015) times less likely to use long-acting contraceptive methods than women with secondary or higher. This indicates that, secondary and above education often leads to women pursuing careers and delaying marriage and childbearing. This naturally increases the need for effective contraception. Wealth index was also found to be a sig- nificant predictor of long-acting contraceptive usage and thus, the odds of a woman with a poor wealth index were 0.336 times (AOR 0.336; 95% CI: 0.243, 464) less likely to use long-acting contra- ceptive methods than women who were rich. Based on the study, marital status was found a significant fac- tor for long-acting contraceptive usage and, the odds of married women were 2.497 times (AOR 4.469; 95% CI: 2.144, 9.316, P- value=0.000) more likely to use long-acting contraceptive methods than women whose current marital status were divorced. Occupation of women also found significant factor of long-act- Article [Healthcare in Low-resource Settings 2025;13:13478] [page 167] Table 1. Percentage distribution on use of long-acting contraceptive with covariates and chi- square test of association results. Contraceptive use Variables Categories Use % Not use % Chi-square df p Age in 5-year 15-24 68.9 31.1 0.027* 25-34 72.7 27.3 7.208 2 35-44 77.5 22.5 Women’s education Illiterate 79.3 20.7 ≤0.001* Primary 66. 33.3 41.288 2 ≥Secondary 53.9 46.1 Wealth index Poor 85.5 14.5 ≤0.001* Middle 69.3 30.7 80.330 2 Rich 62.7 37.3 Heard family planning on radio No 77.2 22.8 25.018 ≤0.001* Yes 61.5 38.5 1 Visited by health extension No 77.7 22.3 17.223 ≤0.001* Yes 66.8 33.2 1 Told about side effects No 75.8 24.2 Yes 72.7 27.3 1.571 1 0.210 Current marital status Single 86.7 13.3 Married 71.9 28.1 3 Divorced 98.6 1.4 35.937 ≤0.001* Widowed 88.8 11.3 Use child as source of income No 78.2 21.8 Yes 68.3 31.7 16.012 1 ≤0.001* Women’s Occupation No Job 70.8 29.2 Government employee 75.0 25.0 17.074 2 ≤0.001* Housewife 86.2 13.8 ing contraceptive usage. The odds of women with no occupation were 2.179 times (AOR: 2.179; 95% CI: 1.291, 3.678, p=0.004) more likely of using long-acting contraceptive methods than women who were housewife’s and, government employed women’s were 0.932 times (AOR: 1.932, 95% CI: 1.176, 3.174, p=0.009) more likely to use long-acting contraceptive methods as compared to housewife women’s. The Hosmer and Lemeshow test yielded an insignificant chi- square value (X²=11.461; p=0.177), indicating that the model is a good fit for the data. Therefore, the logistic regression model is deemed adequate. Discussion This study was conducted to assess the prevalence and factors associated with use of long-acting contraceptive methods among Awi zone adolescent women who can give birth, northweast Ethiopia. The overall prevalence of contraceptive usage was found to be 25.4% and 74.6% of women was not use long-acting contra- ceptive. This prevalence was small as of studies conducted in Jordan (74.8%),9 Malawi (77.9%),10 Tiro Afeta District, South West Ethiopia (74.4%),11 Debre Tabor town, Ethiopia (30.9%),12 and Ghana (44.9%).13 The possible reason for the difference might be variations in the study areas and women in Awi zone district use their child as source of income. The result revealed that illiterate women were 0.512 times less likely to use long-acting contraceptive methods than women who have secondary and above education level controlling other vari- ables in the model [AOR: 0.512; 95% CI: (0.298, 0.879); p£0.001)]. The finding is consistent with a study11 that states that educational level has a statistical significant difference for use of contraceptive methods, respondents with primary and secondary education had about 2 times higher, the result is also consistant with Gafar et al.14 which founds women who had completed sec- ondary and above education had 2.8 times greater than the odds of women who had not completed any formal education for using long-acting contraceptive methods, and Dasa et al.15 which revealed women who have no formal education were 0.59 times less likely to utilize long-acting family planning services as com- pared to women who had primary education and above. Women’s wealth index has found a significant effect on use of long-acting contraceptive methods. The odds of women with poor wealth index were 0.336 times less likely to use long-acting con- traceptive methods than rich women controlling other variables in the model. The finding was similar with a study14 that reveals women classified as the richest by the wealth index were 1.1 times more likely to use contraceptives than those classified as poorest, the study by Johnson,16 which states that the odds of using modern contraceptives were also observed to progressively increase with wealth quintile, being 3.7 times higher among the richest com- pared to the poorest, and the study by Adebowale et al.17 that states using multiple logistic regression on the data reveals that poorest married women were less likely to ever use modern contraceptive. The model results also showed that visited by health extension workers has significant effect on long-acting contraceptive. The finding reveals that women who were not visited by health exten- sion were 73.4% less likely to use long-acting contraceptive meth- ods than women who were visited by health extension. This study was consistent with the finding which was done in Nigeria that states the problem of low access and utilization of modern contra- ceptive experienced by adolescent girls in Niger can be resolved to Article [page 168] [Healthcare in Low-resource Settings 2025;13:13478] Table 2. Parameter estimates of explanatory variables in logistic regression model. Explanatory variables Categories Coefficients SE Wald p AOR AOR 95% C.I. Lower Upper Age in 5-year groups 15-24 0.206 0.205 1.005 0.316 1.228 0.822 1.837 25-34 0.057 0.162 0.124 0.724 1.059 0.771 1.455 35-44 (Ref.) - - - - - - - Mother education Illiterate -0.670 0.276 5.898 0.0015 0.512 0.298 .879 Primary -0.461 0.274 2.826 0.093 0.631 0.369 1.079 Secondary and above (Ref.) - - - - - - - Wealth index Poor -1.091 0.165 43.803 0.000 0.336 0.243 0.464 Middle -0.246 0.199 1.518 0.218 0.782 0.529 1.156 Rich (Ref.) - - - - - - - Heard family planning on radio last few months No -0.216 0.176 1.505 0.220 0.805 0.570 1.138 Yes (Ref.) - - - - - - - Visited by health extension No -0.309 0.144 4.588 0.032 0.734 0.553 0.974 Yes (Ref.) - - - - - - - Current marital status Single 0.029 0.872 0.001 0.973 1.030 0.187 5.683 Married 1.497 0.375 15.95 0.000 4.469 2.144 9.316 Widowed -1.975 1.077 3.363 0.067 0.139 0.0017 1.146 Divorced (Ref.) - - - - - - - Use child as source of income No -0.426 0.140 9.322 0.002 0.653 0.497 0.858 Yes (Ref.) - - - - - - - Mother occupation No Job 0.779 0.267 8.499 0.004 2.179 1.291 3.678 Government Employee 0.659 0.253 6.761 0.009 1.932 1.176 3.174 Housewife (Ref.) - - - - - - - Constant Constant -1.427 0.507 7.907 0.005 0.240 AOR,Adjusted odds ratio; C.I, Confindence Interval; SE, Standard error; Ref., Reference category, some degree by the introduction of Community Health Workers;18 and with the study by Asresie et al.19 that says contraceptive uptake was higher among women who visited by health workers at home 12 months prior to the survey. In this study marital status of women has significant effect on use of long-acting contraceptive methods. Married women are 4.469 times more likely to use long-acting contraceptive methods than divorced women, which indicate that married women were more intended to more children than divorced controlling other covariates in the model. This finding is consistent with the study done in Ethiopia, which revealed that modern contraceptive use among married or in-union reproductive-age women was relatively high compared to other studies done in the region,19 and Niger18 that showed controlling for covariates, the odds of current use of modern contraceptive methods were higher in married adolescent youth. But this finding was contradict with the study done in Malawian,10 which says that the demand for long acting contracep- tive use was higher among sexually unmarried women compared to married women. This is comparable with a study in Malawian where the researcher use only two marital status category (married and un married) and unmarried women often face greater social stigma associated with unintended pregnancies, which can create a stronger motivation to use long acting contraceptive use to prevent such outcomes. The study result portrayed that use of child as source of income is a significant variable for use of long-acting contraceptive meth- ods. Mothers who were not used their child as source of income were 65.3% less to use long-acting contraceptive methods than women who used their child as source of income controlling other covariates in the model. Occupation status of women has significant effect on the use of long-acting contraceptive methods. The result showed that women’s whose occupation were no job is 2.179 times more likely to use long-acting contraceptive methods than house wife women and government employed women were 1.932 times more likely to use long-acting contraceptive methods than housewife’s women. This finding was consistent with the study done in Debre Berhan town, Ethiopia.12 Our study reveals that a respondent whose occu- pation is employed was found to be 13.992 times more likely to had long-acting family planning compared with self-employed. A study done in Bangladesh20 was also consistent with this study and says that occupation had an emergent relation with contraceptive usage of employed woman had 26% higher chance of using con- traception than an unemployed woman. The factors “heard about side effects” and “family planning on the radio” were found to be non-significant determinants for long- acting contraceptive use. This may be due to the fact that aware- ness alone is not enough; individuals must also have access to fam- ily planning services. If barriers such as distance, lack of supplies, or high costs exist, increased awareness may not necessarily lead to higher usage. Conclusions This study, conducted in the Awi Zone of Northwest Ethiopia, examined the utilization of long-acting contraceptive methods among 1,334 women of reproductive age. The findings reveal a complex picture of contraceptive use, influenced by a range of demographic and socioeconomic factors. The study utilized bivari- ate and multivariable logistic regression to identify significant pre- dictors of long-acting contraceptive method usage among women. The final multivariable analysis revealed that women’s educational level, wealth index, marital status, occupation, and the use of chil- dren as a source of income were significant factors. Future studies should employ qualitative methods to under- stand women’s contraceptive perceptions and barriers, alongside longitudinal research to track intervention impacts. Investigating male partner and community leader influence is crucial. Comparative studies across Ethiopian regions, considering spatial analysis, cultural and infrastructural differences, will further refine intervention strategies. These research avenues will provide a more comprehensive understanding of contraceptive behavior and opti- mize public health efforts. Limitations Because of missing data all explanatory variables were not included and since this study was retrospective type recall bias might be introduced. While the study acknowledges the need for qualitative research, it primarily relies on quantitative methods. The absence of qualitative data limits the depth of understanding regarding women’s perceptions and experiences. 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