Hrev_master [page 6] [Healthcare in Low-resource Settings 2016; 4:5680] Knowledge, attitude and practice of contraceptive use among female students of Dilla secondary and preparatory school, Dilla town, South Ethiopia, 2014 Samuel Kusheta Katama,1 Desalegn Tsegaw Hibstu2 1Department of Health Extension, Hossana College of Health sciences, Hossana; 2Department of Reproductive Health, Hawassa University, Hawassa, Ethiopia Abstract Family planning is known not only as a fun- damental intervention for improving the health of women but also as a human right. The aim of this study was to assess the current knowledge, attitude and practice of contraceptive use among female students in Dilla secondary and preparatory school, Dilla, South Ethiopia, 2014. A cross sectional study was conducted among 288 female students in Dilla secondary and preparatory school, south Ethiopia, June 19- 29/2014. A simple random sampling technique was used to select the study subjects. The data was collected using a self-administered struc- tured questionnaire. The data was analyzed by SPSS 20. Chi-square test was used to identify associated factors. A total of 263 female stu- dents were involved in this study, of which 249 (94.7%) had good knowledge about contracep- tion. The three most frequently identified methods were injectable form (83.9%), oral contraceptive pills (72.7%) and condom (48.6%). A total of 15.7% respondents ever used contraceptive. Among the users, 56.4% used oral contraceptive pills, and 23.1 and 10.2% used injectable form and condom, respectively. In spite of the fact that most respondents had good knowledge of contraception, their attitude and practice was low. Emphasis needs to be given on disseminating health information concerning the attitude and practice of contra- ceptive method. Introduction Family planning is known not only as a fun- damental intervention for improving the health of women but also as a human right. The basis for action in family planning must enable cou- ples and individuals to decide freely and responsibly the number and spacing of their children.1 Ethiopia is the second most populous country in Africa. Its population has increased nearly seven times from 11.8 million at the beginning of the 20th century to about 80 mil- lion today. The total fertility rate of Ethiopia is 4.8 with estimated population growth rate is 2.7% per year, contraceptive prevalence 29%.2 In Ethiopia, unwanted pregnancy is a seri- ous issue where more than 60% of the pregnan- cies in adolescents are unwanted resulting from unprotected sexual intercourse which is an alarming figure, and most of these pregnan- cies particularly in adolescents end up with unsafe abortion.3 An African woman’s chance of dying from pregnancy related causes: obstruct- ed labor, postpartum hemorrhage, pregnancy induced hypertension, post partum infection and unsafe abortion average 870 per 100,000 live births in contrast to developed countries which is 27 per 100,000 live births.4 One of the big challenges to the reproductive health of young adults in developing countries like Ethiopia is unintended pregnancy. As a result of the decreasing age of menarche and onset of sexual activity, youths are facing early unplanned and unprotected sexual intercourse leaving them vulnerable to unwanted pregnan- cies and invariable abortions.5 About 3.7 million unsafe abortions are performed each year in sub-Saharan Africa and about 23,000 African women die from its complication. East African women face the highest life time risk of mater- nal death of 1 in 12 compared with 1 in 3700 women in North America.6 Low-income countries are confronted with a vicious cycle: efforts to improve living stan- dards and to alleviate poverty are overwhelmed by the need to provide basic services and jobs for the growing number of people. Provision of family planning service has become the inter- vention of choice to stabilize demographic explosion.7 There are many causes for the low contra- ceptive prevalence rate that needs to be explored. It will be easy to design implementa- tion methods for the alleviation of conse- quences of not using contraceptives if the rea- sons are identified. The problem is more acute among teenagers due to various reasons. A study done on knowledge, attitude and practice of family planning methods and other repro- ductive health diseases including HIV/AIDS among school adolescents in seven towns of Ethiopia showed that most of the sexually active school adolescents did not use contra- ception.8 This paper attempts to assess the cur- rent knowledge, attitude, and practice of con- traception among female students of Dilla sec- ondary and preparatory school. Materials and Methods Study area and period The study was conducted in Dilla town, the capital of Gedeo zone [Southern, Nation Nationalities and People’s Regional state (SNNPR)]. The town is located at a distance of 359 KM from Addis Ababa, capital city of Ethiopia and 90 KM from Hawassa, the capital city of SNNPR, Ethiopia. Cross sectional study design was used from June 19-29/2014. Population The source population was made up of all Dilla secondary and preparatory high school students enrolled in the year 2014 and students who were absent and seriously sick students on the day of data collection were excluded in this study. The study population included all ran- domly selected students in Dilla secondary and preparatory high school in the year 2014. Study variables The study variables were developed based on the different literature reviews and from previ- ous studies. The outcome variables are: knowl- edge of contraceptive use, attitude towards con- traceptive use, and practice of contraceptive use. The personal variables are: age, ethnicity, religions, marital status, educational level, rea- sons for not using contraception, and source of information. In this paper knowledge of contra- ception was defined as awareness of women about family planning methods or having infor- mation about contraception. The study subjects Healthcare in Low-resource Settings 2016; volume 4: 5680 Correspondence: Desalegn Tsegaw Hibstu, Department of Reproductive Health, Hawassa University, Hawassa, Ethiopia. E-mail: samkush2012@yahoo.com, desuethiopia@ yahoo.com Key words: Family planning; Contraceptive use; Dilla; Ethiopia. Conflict of interest: the authors declare no poten- tial conflict of interest. Contributions: SKK and DTH participated from the conception to the end of this manuscript. Received for publication: 11 December 2015. Accepted for publication: 16 January 2016. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright S.K. Katama and D.T. Hibstu 2016 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2016; 4:5680 doi:10.4081/hls.2016.5680 Non co mmerc ial us e o nly needed to answer >70% of the question on knowledge section to be classified as knowl- edgeable, practice is defined as the overt behavior, habit or customs of women using contraception. The study subject were to answer the 1st question yes on the practice sec- tion and then to specify the type to be classified as good or poor practice. The study subjects were considered to have good attitude if they gave appropriate answers for >70% of the ques- tions on attitude section. Sample size determination and sampling procedure The sample size was determined using sin- gle population proportion formula: n=z2�/2(pq)/d2 where n=sample size, Z=reliability coefficient with 95%confidence interval, p=prevalence of contraceptive use (29%)[2], q=1-p, d= Standard error allowed taken as 5%. And the final sample size was 288 with 10% non- response rate after using the sample size cor- rection formula. To get the representative sample stratifica- tion was done by grades (grade nine, ten, eleven and twelve). Based on this the strata was done by considering number of sections from each grade. The final sample size was obtained and proportionally allocated for each section. The total samples were taken from the sampling frame using simple random sampling technique available from their identification number using computer generated random number from each class. The selected students were gathered in a room and provided with a self-administered questionnaire that was filled out in the same room. Data collection and quality control procedures Pre-tested and self-administered structured questionnaires were used. Two day training was given to data collection facilitators. Two principal investigators supervised the overall data collection and checked the completeness of the questionnaire for consistency. The ques- tionnaire was prepared in the English language and translated to Amharic (local language) and translated back to English. After data collection, questionnaires were reviewed and checked for completeness and relevance by the principal investigators. Data processing and analysis After data collection, each questionnaire was checked for completeness and code was given before data entry. Data was cleaned and entered into computer by using Epi Info version 3.5.3 and the analysis was done using SPSS version 20.0. Data was edited and cleaned before data analysis. Descriptive statistics and chi-square tests were used and significance of tests were decided at P<0.05. Ethical consideration Ethical clearance was obtained from the eth- ical clearance board of Dilla University, College of Health Sciences. All participants’ right to self-determination was respected. The study participants were informed about the purpose of the study and informed verbal consent was secured. Results Socio-demographic characteristics A total of 263 female students participated in the study with a response rate of 91.3%. Age of the study subjects ranged from 14-22 years with median age of 19. Among the studied female students, 170 (64.6%) were Gedeo followed by Amahara 41 (15.6%) by ethnicity. Two hundred forty eight (94.3%) of the respondents were single and 119 (45.2%) of the study partici- pants were from grade nine (Table 1). Contraceptive knowledge Of the students, 249 (94.7%) had heard about contraceptives. All of them correctly iden- tified at least one contraceptive method. The three most frequently identified contraceptive methods were injectable form 209 (83.9%) fol- lowed by oral contraceptive pills 181 (72.7%) and condom 121 (48.6%) (Table 2). The sources of contraceptive knowledge were tele- vision, 104 (41.8%), radio 54 (21.7%) and teachers 49 (19.7%) (Table 3). It was found that 191 (76.7%) said that contraceptives are used to prevent unwanted pregnancy, 209 (83.9%) to limit or space childbirth, and 48 (19.3%) answered to prevent sexually transmitted dis- eases (Table 4). Attitude towards contraception One hundred seventy eight (71.5%) students had a favorable attitude towards contracep- tives. Among them, 111 (63.4%) are orthodox christians having positive attitude, 56 (31.5%) protestant, 6 (3.4%) catholic and 5 (2.8%) of muslim students have positive attitude towards contraceptive (Table 5). Contraceptive practice A total of 39 (15.7%) respondents had ever used contraceptive method. Of 39 students who practiced contraceptive 26 (66.7%) were unmarried and 13 (33.3%) were married. Among those that practiced contraceptives 19 (48.7%) were orthodox, 15 (38.5%) were protestant, 3 (7.7%) were muslim, and 2 (5.1%) were catholic students. The commonly used contraceptive method was pills, 22 (56.4%) fol- lowed by injectable, 9 (23.1%) and condom 4 (10.2%) (Table 6). Discussion Family planning is defined by WHO as a way of thinking and living that is adopted voluntar- ily, upon the basis of knowledge, attitudes and responsible decisions by individuals and cou- ples, in order to promote the health and welfare of family groups and thus contribute effectively to the social development of a country. This study showed about 94.7% of respon- dents had knowledge of contraceptive method. This finding was in agreement with the report- Article Table 1. Socio-demographic characteristics of female students of Dilla secondary and preparatory school, Dilla town, South Ethiopia, July 2014. Variables n % Age (years) 14-16 21 8.0 17-19 196 74.5 20-22 46 17.5 Religion Orthodox 172 65.4 Protestant 75 28.5 Muslim 9 3.4 Catholic 7 2.7 Ethnicity Gedeo 170 64.6 Amhara 41 15.6 Oromo 19 7.2 Tigre 7 2.7 Sidama 12 4.6 Gurage 15 5.3 Marital status Single 248 94.3 Married 15 5.7 Grade 9th 119 45.2 10th 42 16.0 11th 75 28.5 12th 27 10.3 Table 2. Knowledge of contraceptive meth- ods among female students of Dilla sec- ondary and preparatory school, Dilla town, South Ethiopia, July 2014. Variables n % Heard contraceptive Yes 249 94.7 No 14 5.3 Method known Injectable 209 83.9 Oral pills 181 72.7 Condom 121 48.6 Calendar (rhythm) 99 39.8 Coitus interrupts 94 37.7 Loop (IUCD) 83 33.3 Norplant® 49 19.7 Tubal ligation 71 28.5 Breast feeding 47 18.9 IUCD, intrauterine contraceptive device. [Healthcare in Low-resource Settings 2016; 4:5680] [page 7] Non co mmerc ial us e o nly [page 8] [Healthcare in Low-resource Settings 2016; 4:5680] ed contraceptive knowledge level of adolescents to be 93-98%.9-12 Still, this finding was higher than reports of students from other urban cen- ters of the country where contraceptive knowl- edge level varies from 54% in Harar13 to 75-83% in North Gondar.14 This magnitude was also comparable with the level of adolescents’ con- traceptive knowledge in Asia, North Africa, the Caribbean and Latin America, where the level of adolescents’ knowledge on contraception was above 90%.15 This might be due to the bet- ter information exposure and communication that school adolescents now have and influence of mass media. Perhaps, it could be due to the fact that the most widely available method of family plan- ning is oral contraceptive pills, the most famil- iar method obtained in this paper was oral con- traceptive pill, which was congruent with other studies. About seventy percent of study subjects had heard about emergency contraception. A study conducted in Nigeria and Addis Ababa University showed that 58 and 43.3% knew about emergency contraception, respective- ly.16,17 The result of this study was higher; the difference could be due to the difference in the population studied and time interval between the studies. Contraceptive use in this study was 15.7%. A research done in North Gondar showed that contraceptive use was 30.7%,18 while a study done in Harar was 20%.13 The pos- sible reason for this difference could be poor attitude towards contraceptive use in the pres- ent study because of religious and cultural rea- son, and variation in the population studied. The major source of information on contra- ception in this study was television (41.8%) while it was 23.8% in a study done in North Gondar.18 This difference might be due to increasing number of televisions per house- hold with increasing emphasis by the govern- ment through different attractive announce- ments and programs on television. In this study, it was observed that pharmacy/drug vender was the main source of contraceptive method accounting for 87.2% (Figure 1). A study done in Jimma urban population showed 98.96% from clinic and pharmacy.16 Among those who did not use any method of contracep- tive in this study, 46.5% were not using for cul- tural reason, and 27.6% for religious reason and 23.7% because of lack of knowledge (Figure 2). A study done in north Gondar showed that majority of non-users did not use because of lack of knowledge or access to serv- ice.18 This could be the difference in the popu- lation studied and changes in the study period. Conclusions This study showed that most of the students Article Figure 1. Distribution of respondents by source of contraceptive used among Dilla sec- ondary and preparatory school, Dilla town, South Ethiopia, July 2014. Figure 2. Distribution of respondents by their reason for not using contraceptive in Dilla secondary and preparatory school, Dilla town, South Ethiopia, July 2014. Table 3. Source of contraceptive knowl- edge in Dilla secondary and preparatory school female students, Dilla town, South Ethiopia July, 2014. Source n % of knowledge (tot=249) TV 104 41.8 Radio 54 21.7 Teacher 49 19.7 Friends 40 16.1 Health worker 24 9.6 Books 18 7.2 Magazines 15 6 Table 4. Distribution of female students in Dilla secondary and preparatory school by their knowledge about importance of con- traception. Importance of contraception n % Prevent unwanted pregnancy 191 76.7 Prevent STD 48 19.3 Limit/space child birth 209 83.9 Treat menstruation pain 28 11.2 Prevent abortion complications 12 4.8 STD, sexually transmitted disease. Non co mmerc ial us e o nly [Healthcare in Low-resource Settings 2016; 4:5680] [page 9] had knowledge of contraception. Predominant methods known by students were injectable, oral contraceptive pills and condom, respective- ly but the number one method used by students was oral contraceptive pills. Older adolescents (age 18-22 years) and higher grades (11th and 12th students) ever used contraceptive methods than younger ones and lower grades (Grade 9 and 10). Television, radio, and teachers were found to be the most important source of infor- mation for promoting utilization of contracep- tives. Marital status was found to be associated with higher rates of contraceptive use. Among the non-users, the majority of respondents did not practice for religions and cultural reason and lack of knowledge. Most women have good attitude towards contraceptives. Information, education and communication activities regarding utilization of modern contraceptive methods among adolescents and their impor- tance should be strengthened by the Ministry of Health through mass media messages and encouraging school health programs. Including family planning in the educational curriculum both at elementary and secondary schools needs emphasis, so that knowledge and prac- tice of modern contraception can be utilized early at least for those who are not out of school. Community health education programs regarding culture need to be planned and car- ried out to the community at large. Encouraging mini media programs and estab- lishing reproductive health clubs should be pro- moted by school officials. References 1. WHO. Improving access to quality cares in family planning. Geneva, Switzerland: WHO; 1996. 2. Central Statistical Agency-ICF International. Ethiopia demographic and health survey. Addis Ababa, Ethiopia, and Calverton, MA, USA: Central Statistical Agency and ICF International; 2012. 3. Tilahun D, Assefa T, Belachew T. Knowledge, attitude and practice of emer- gency contraceptive among Adama University female student. Ethiopian J Reprod Health 2010;20:195-202. 4. Ethiopian Population. Ethiopian linkage between population and economy, 2007. Available from: http://www.ethiopianpopu- lation.com 5. Park K. Textbook of preventive and social medicine. 22th ed. Jabalpur: Banarsidas Bhanot Publ.; 2013. 6. World Bank. Effective, family planning pro- grams. Washington, DC: Wordl Bank; 1993. 7. WHO. Community based distribution of contraceptive. A guide for program manag- er. Geneva, Switzerland: WHO; 1995. 8. Birhan Research & Development Consultancy. Ethiopia: knowledge, atti- tudes and practices in family planning. Results from September 2004 survey of Amhara, Oromia, SNNPR and Tigray regions. Available from: pdf.usaid.gov/pdf_docs/Pnadp662.pdf 9. Aklilu K, Hailom B. Youth reproductive health in Ethiopia. Ethiopia demograhic and health survey. Calverton, MA: ORC Marco; 2002. 10. Berhane F. Health problems and service preferences of school adolescents in Addis Ababa with emphasis on reproductive health. Department of Community Health: Addis Ababa, Ethiopia; 2000. 11. Tilahun T, Coene G, Luchters S, et al. Family planning knowledge, attitude and practice among married couples in Jimma zone, Ethiopia. PLoS One 2013;8:e61335. 12. Kasahun S. Sexual behavior, contraceptive practice and knowledge of Aids of high school students in Addis Ababa. Addis Ababa: University of Addis Ababa; 1997. 13. Bisrat F. Knowledge, attitude and practice of contraceptive among high school stu- dents in Harar town, Eastern Ethiopia. Ethiopian J Health Dev 1994;32:151-60. 14. Kebede Y. Contraceptive prevalence and factors associated its usage in Gondar Town, North Ethiopia. Ethiopian J Health Dev 2000;14:32-9. 15. Sigh S, Kluif D. The likelihood of induced abortion among women hospitalized for abortion complication in four Latin American countries. Int Fam Plan Persp 1993;19:134-41. 16. Aziken ME, Okonta PI, Ande AB. Knowledge and perception of emergency contraception among female Nigerian undergraduates. Int Fam Plan Persp 2003;29:84-7. 17. Tamire W, Enquselassie F. Knowledge, atti- tude and practice on EC among female stu- dents at higher education, Addis Ababa, Ethiopia. Addis Ababa: University of Addis Ababa; 2005. 18. Shiferaw M. Determinants of contracep- tive use in Jimma herbal population, south West Ethiopia. Addis Ababa: Family Guidance association of Ethiopia; 1990. Article Table 5. Contraceptive knowledge, attitude and practice in different religious groups of Dilla secondary and preparatory school female students, Dilla town, South Ethiopia, July 2014. Knowledge Attitude Practice Religion Yes No Yes No Yes No n (%) n (%) n (%) n (%) n (%) n (%) Orthodox 162 (94.2) 10 (5.8) 111 (64.5) 61 (35.5) 19 (11.0) 153 (89.0) Protestant 73 (97.3) 2 (2.7) 56 (74.7) 19 (25.3) 15 (20.0) 60 (80.0) Muslim 9 (100) 0 (0.0) 5 (55.6) 4 (44.4) 3 (33.3) 6 (66.7) Catholic 5 (71.4) 2 (28.6) 6 (85.7) 1 (14.3) 2 (28.6) 5 (71.4) Significant test X2=8.32; P=0.04 X2=13.66; P=0.034 X2=3.19; P=0.36 Table 6. Contraceptive usage among Dilla secondary and preparatory school female stu- dents, Dilla town, South Ethiopia, July 2014. Practice n % Ever used Yes 39 15.7 No 210 84.3 Type used Oral pills 22 56.4 Injectable 9 23.1 Condom 4 10.2 Calendar (rhythm) 2 5.1 Coitus interrupts 1 2.6 Norplant® 1 2.6 Non co mmerc ial us e o nly