KNOWLEDGE, ATTITUDE AND PRACTICE ON FAMILY PLANNING AMONG URBAN AND RURAL SECONDARY SCHOOL STUDENTS IN THE GAMBIA: A COMPARATIVE STUDY
Contents
1.3 JUSTIFICATION OF THE STUDY
1.6 SIGNIFICANCE OF THE STUDIES
2.1 FAMILY PLANNING UTILIZATION
2.3 KNOWLEDGE OF FAMILY PLANNING
2.5 REASONS FOR NOT USING MODERN CONTRACEPTIVES
3.7 VALIDITY AND RELIABILITY OF INSTRUMENTS
KNOWLEDGE, ATTITUDE AND PRACTICE ON FAMILY PLANNING AMONG URBAN AND RURAL SECONDARY SCHOOL STUDENTS IN THE GAMBIA: A COMPARATIVE STUDY
Family Planning help individuals and couples to anticipate and attain their desired number of children in addition to the spacing and timing of their births. This is achieved by using modern contraceptive methods. Family planning encompasses a wide range of services such as sex education, prevention and management of sexually transmitted infections, preconception counseling and management and infertility management1.
The use of family planning services have realized a steady increase in many countries of the world. According to WHO, despite the positive increase there are still over 200 million women worldwide who would like to avoid a pregnancy but are not using an effective method of contraception due to reasons like lack of supplies, cultural, political barriers and poor quality of services2.
According to the United Nation’s Family Planning Fund(UNFPA), about 64 % of women of reproductive age (15-49), married or in a union, are using some form of contraception, either modern or traditional3. The report further revealed the current contraceptive prevalence rates (CPR) as 68.5%in Asia, 51.5% in Arab States, 65% in Eastern Europe and Central Asia,72.6% in Latin American and the Caribbean, 38.6 in Eastern and Southern Africa and the least West and Central Africa with 17.63. It has been observed that there has been a decline in the prevalence of induce abortion from 1995. As at 2008 the prevalence of induced abortion globally was 28%3. The study further revealed the trends in various region of the world as; Africa 29%, Asia 28%, Europe 27%,Latin America 32%, Northern America 19% and Oceania 17%3.
Adolescents are an important resource of any country. There is no universally accepted definition of adolescence bracket. WHO definition of adolescent is anyone between the ages of 10 and 19 years4. It is recognized that many of the health related behaviors that arises during adolescence has implications for the present and future health and development 5. This age group account for 1.8 billion of the world’s population .Adolescents comprises 20% of the world’s total population and the rapid changes in the population growth are realized in developing countries6.
The changing moral, social values and shift in the standard of societal behavior from conservatism to liberal interaction between both sexes is attributed largely to exposure to the media especially television and movies. Adolescents find themselves sandwiched between a glamorous western influence and a stern conservatism at home, which strictly forbids discussion on sex. This dichotomy aggravates the confusion among adolescents7. This has led to increase in premarital sexual activity, pregnancy among unmarried girls apart from the increasing incidence of abortion & Sexually Transmitted Infections7.
Despite the global reduction in maternal deaths, pregnancy related mortality remains the second leading cause of death among adolescent girls age 15-19 years8. There are a lot of factors contributing to these death such as unsafe abortion, obstructive labors because of the size of their pelvic. It was also found out that adolescents don’t have access to information about their sexuality and reproductive health and as a result, they are less likely to seek for or utilize reproductive health services. Adolescence pregnancy is a major public health problem because it does not only increase their risk of instrumental delivery, obstetric complications like obstructed labor and obstetric fistulae but it also increases their risk of having a poor pregnancy outcome for both the mother and the baby 8. Adolescent also have a higher risk of dying from pregnancy related causes when compared to older women because their pelvis and reproductive organs are not fully developed to begin reproduction.
According to the United Nation Family Planning Fund (UNFPA) pregnancies among girls below 18 years have irreparable consequences and some of these consequences are; it violates the rights of girls, life-threatening consequences in terms of sexual and reproductive health, and poses high development costs for communities, particularly in perpetuating the cycle of poverty. Early pregnancy will have negative affect on their education, health needs, increase risk of violence in the society, increase HIV infection and maternal deaths and disability9.
In The Gambia adolescents constitute 23% of the population, approximately 386 thousand and like their peers in other developing countries, they are faced with early physical maturation10. As a result, many of them venture into early unprotected sexual activities which predisposes them to unintended and often unwanted pregnancies 10.The consequences of unwanted pregnancy include, unsafe abortion practices which exposes them to pelvic inflammatory diseases, ectopic pregnancy, and secondary infertility, baby-dumping, sexually transmitted infections, including HIV/AIDS, involvement in drug use and abuse 11. However, even though there are no data on the impact on the consequences of limited Family Planning services to students, the uptake of family planning services is very low12.
Young people’s sexual rights are denied by both religious and traditional forces in the Gambia which promotes early marriage and stigmatizes premarital sex and pregnancy outside marriage. Misinformation about sex and lack of youth friendly sexual and reproductive health services also poses challenges to the sexual and reproductive health of young girls13 .
There are 1.8 billion young people between the ages of 10-24 in the world and this cohort of age bracket is the fastest growing in most of the developing countries 14 This is a time when they are at a crossroad most especially concerning sexual and reproductive health where they have limited information.
Lack of sexual reproductive health information and service has led to many health problems. Globally, there are more than 2 million 10-19 year old living with HIV and about one in seven of all new cases of HIV infection occurred during adolescence 14.
Young people’s reproductive health is often over looked. Health facilities frequently fail to provide young adult with specialized reproductive health information and counseling services despite the fact that they are increasingly exposed to reproductive health risks. It is estimated that about 16 million girls aged 15-19 and 1 million girls under the age of 15 give birth annually and most of the births occur in low and mid-income countries 15.
Complications during pregnancy and childbirth are a common cause of death among young girls in developing countries. It is established that complication during pregnancy and childbirth are the 2nd leading killer of females and young women in developing countries,16.
The social setting has a negative toll in the adolescents’ sexual and reproductive health. In many settings, sex is not a matter of discussion in the home. In rural Gambia, students are considered to be “small children” who are not expected to have sex17. This type of thinking poses a barrier to access and makes reproductive health services not student youth-user-friendly. These research findings will be used to establish the existing gap between the adolescent and provision of reproductive health services and it will help to improve adolescent reproductive health.
According to UNFPA, 23.3 million women were helped to have access to modern family planning services and also bout 700 million condoms and other commodities were procured in 201518. The turnover of their investment averted 34,000 maternal deaths,12.3 million unintended pregnancies, 4.4 million abortions including 3.9 million unsafe abortion and 220,000 child death18.
The rationale of the study on students is that they make part of the adolescent cohort that are neglected in the health care system. The Gambia health demography survey (2013) reveals that the adolescent birth rate is 88.1%. This further shows that 18% of the adolescent women aged 15-19 are already mothers or pregnant with their first child19. This trend is similar to the figures within the sub-Saharan Africa sub region13.
A study on intervention to improve adolescents’ contraceptive behavior in low and middle income countries revealed that 15% of maternal death in sub-Saharan African happens among adolescents between the ages of 15 to 19yrs 16.
A study conducted among university students in Saudi Arabia identified that young people are faced with a number of risks to their sexual and reproductive health including adolescent pregnancy, sexual violence, and unmet family planning 20.
Lack of adequate knowledge and utilization of sexual and reproductive health services by secondary school students is a big public health challenge most especially when government looks forward to reduce maternal and child morbidity and mortality in the Gambia. Generally, adolescents’ sexual and reproductive health issues are neglected in service delivery and research in the Gambia. Most of the literature reviewed doesn’t really attempt to find out students’ knowledge, attitude and utilization of sexual and reproductive health services. The findings of his study will pave the way towards addressing issues related to their sexual and reproductive health. The rate of Sexual &Reproductive Health services by students is not known nor does the barriers for non-use of contraceptives is known.
According to World Young Women’s Christian Association about 68% of sexually active unmarried adolescents have an unmet need for modern contraceptive in Sub-Saharan Africa including Gambia11.
The 2013 Gambia Health Demography Survey (DHS) revealed that contraceptive use was lower among all women than among currently married women. It further showed that sexually active unmarried women are by far the most likely to be using contraception. If the 2013 HDS is to be compared with previous surveys it was evident that family planning uptake and continuity is on the decline in the country19. It is evident that the uptake of family planning is disproportionate across the various regions with Banjul being the highest and Upper River Region having the lowest19.
Unplanned and unwanted pregnancy among unmarried adolescents is a challenge for many developing countries including The Gambia. Currently in the Gambia there is no comprehensive program that addresses the reproductive health needs of adolescents leading to lack of accurate and appropriate sexual information that will prevent them from unplanned pregnancy21.
A report by the Ministry of Health and Social Welfare, The Gambia revealed that about 18% adolescent women age 15 to 19 are already mothers or pregnant with their first child22. The report further revealed that rural teenagers are twice more likely to have their first child earlier than urban girls22.
Currently, there is very limited data on students’ knowledge and utilization of sexual and reproductive health services in the Gambia thus this study will form the bases for further research in this area.
The goal of the study is to compare the knowledge, attitude and practice on family planning among rural and urban secondary school students in the Gambia. The specific objectives are (1) to determine the knowledge of secondary school students on family planning (2) To assess the attitude of secondary school student on family planning service (3) To identify practices of family planning services among students.
The study intends to answer the following research question;
The hypothesis of the study is geographical location has no effect on knowledge and attitude of students on family planning.
Geographical location has no effect to access and uptake of family planning services.
Sexual and reproductive health problems like Abortion, risky sexual practice, unwanted pregnancy, Sexually Transmitted Infection (STI) and sexual violence are common phenomena among students and very little research have been conducted to present the magnitude of the problem. Therefore, this assessment is believed to give the present image of reproductive health related issues among of the students within the study area, which may help the concerned authorities to take necessary actions based on the findings. The study may also provide baseline information for further studies that may be conducted in similar issues.
This study will be conducted only on secondary schools in Region II & IV Education Directorates of The Gambia. The target population is all students attending secondary school education in these two regions.
Gambia has six regional education directorates. A simple random sampling was employed. Two regions were picked and they happened to be Region II&IV.
These two education regions were randomly selected using simple random sampling technique. The names of all the regional education directorates in The Gambia were written on small pieces of papers. The balloting started by picking the urban directorate. The Gambia has two urban regional education directorates, the names of the two directorates were balloted and region II was picked.
The rural regional education directors are four in number. The balloting procedure employed in selecting the urban regional education directorate was used and region IV was selected.
Knowledge: is awareness and understanding that one has gained on reproductive health issues through learning and practice and respondents was considered to be knowledgeable if he/(s) correctly answered greater than or equal to 70% of the total knowledge assessing questions .
Attitude –The way of thinking to which family planning should be provided to and an intention to use family planning services in the future
Practice -Utilization of at least any family planning services
The conceptual framework to be used in the study will be the Health Belief Model (HBM) The HBM is a cognitive, interpersonal framework that views humans as rational beings who use a multidimensional approach to decision-making regarding whether to perform a health behavior. The model is appropriate for complex preventive and sick-role health behaviors such as contraceptive behavior.
Putting in mind that family planning is a dynamic and complex set of services, programs and behaviors towards regulating the number and spacing of children within a family. Contraceptive behavior, refers to activities involved in the process of identifying and using a contraceptive method to prevent pregnancy and can include specific actions such as contraceptive initiation, continuation or discontinuation, misuse, nonuse, and more broadly compliance and adherence
1.9.1 Constructs of the HBM for Family Planning
The constructs of the Health Belief Model which will influence the utilization family planning are being discussed below.
Perceived Susceptibility and Severity – the perceived possibilities of an unwanted pregnancy and its associated problems provides the incentive to use contraception. This considers personal feelings of the seriousness of becoming pregnant, based upon subjective assessment of medical and social consequences of pregnancy and childbearing most especially in a conservative society where people frowns at outside wedlock pregnancies. This construct may include factors like fear of body changes or pregnancy complications, or worry of quitting school, which can impact the likelihood of contraceptive use23.
Perceived Benefits
Perceived benefits relate to the perceived effectiveness, feasibility and other advantages of using a contraceptive method to prevent pregnancy vis-à-vis the perceived barriers. Through a cost-benefit analysis, the perceived ratio of a contraceptive’s benefits to its barriers helps determine the preferred and specific contraceptive action and method23.
Perceived Barriers – Perceived barriers are negative consequences of using contraception. This dimension includes factors such as perceived side effects of hormonal contraception. These fears have been found to be potential reasons why people may not use contraceptive .Disadvantages have been found to inhibit contraceptive use23.
Cues to Action – theseare internal and external stimuli that trigger a consciousness of the perceived pregnancy threat and facilitate consideration of using contraception to remedy the threat. This may include symptoms like missed menses after intercourse (internal stimuli) or contraceptive communication from the media, and worry from a sexual partner or counseling by a health care provider23.
Figure 1. Constructs of the Health Belief Model, as Applied to Contraceptive Behavior
Source: Glanz et al, 2002, p. 52
Family planning is one of the great public health achievements in the 20th century. Family planning allows people to attain their desired number of children and determine the spacing of pregnancies. It is achieved through use of contraceptive methods and the treatment of infertility. Promotion of family planning and ensuring access to preferred contraceptive methods for women and couples is essential to securing the well-being and autonomy of women, while supporting the health and development of communities 1.
The other benefits of family planning among others are;
Preventing pregnancy-related health risks in women – when a woman can make an informed choice whether to be pregnant or not, it has a direct bearing on her health and the wellbeing of the entire family. Family planning allows the spacing of pregnancies and can delay adolescents from becoming pregnant thus reducing their risk of pregnancy related health issues and death from early childbearing. It prevents unwanted pregnancies and unsafe abortion consequences. Family planning enables women who wish to limit the size of their families to do so. Evidence suggests that women who have more than 4 children are at increased risk of maternal mortality (1).
Reducing infant mortality – Family planning can prevent closely spaced and ill-timed pregnancies and births, which contribute to some of the world’s highest infant mortality rates. Infants of mothers who die as a result of giving birth also have a greater risk of death and poor health(1).
Helping to prevent HIV/AIDS – Family planning reduces the risk of unintended pregnancies among women living with HIV, resulting in fewer infected babies and orphans. In addition, male and female condoms provide dual protection against unintended pregnancies and against STIs including HIV (1).
Empowering people and enhancing education – Family planning enables people to make informed choices about their sexual and reproductive health. Family planning represents an opportunity for women to pursue additional education and participate in public life, including paid employment in non-family organizations. Additionally, having smaller families allows parents to invest more in each child. Children with fewer siblings tend to stay in school longer than those with many siblings1.
Reducing adolescent pregnancies – Pregnant adolescents are more likely to have preterm or low birth-weight babies. Babies born to adolescents have higher rates of neonatal mortality. Many adolescent girls who become pregnant have to leave school. This has long-term implications for them as individuals, their families and communities1.
According to World Health Organization contraceptive use has increased in many parts of the world, especially in Asia and Latin America, but continues to be low in sub-Saharan Africa15. Globally, use of modern contraception has risen slightly, from 54% in 1990 to 57.4% in 2014. In Africa it went from 23.6% to 27.6%, in Asia it has risen slightly from 60.9% to 61.6%, and in Latin America and the Caribbean it rose slightly from 66.7% to 67.0%15Use of contraception by men makes up a relatively small subset of the above prevalence rates. The modern contraceptive methods for men are limited to male condoms and sterilization (vasectomy).
A study carried out in Ikeji Arakeji, Osun State, Nigerian showed that women with higher education are more likely to plan their families, have fewer children, have better access to health services, and experience less maternal mortality24.
Unmet need family planning is defined as “those who are fecund and sexually active but are not using any method of contraception, and report not wanting any more children or wanting to delay the next child. The concept of unmet need points to the gap between women’s reproductive intentions and their contraceptive behavior”25.
WHO estimated 225 million women in developing countries would like to delay or stop childbearing but are not using any method of contraception. Reasons for this include25:
The unmet need for contraception remains too high in many parts of the world. In Africa, 23.2% of women of reproductive age have an unmet need for modern contraception while in Asia, Latin America and the Caribbean – regions have relatively high contraceptive prevalence – the levels of unmet need are about 11 %25.
Knowledge on family planning services is an important step toward gaining access to contraceptive methods and using a suitable method in a timely and effective matter26. A survey conducted in in Osun State, Nigeria revealed that all ever-married and currently married women (100% each) know at least one method of family planning 26. The survey showed that people with little or no education and poor have the least knowledge about family planning26. The same survey showed that geographical location has an effect on knowledge on family26. It showed urban men have better access to family planning information through the mass media than rural men26. Additionally, education had a positive association with access to family planning information through the media.
A study in Tanzania showed that 98% of Tanzanian population have access to family planning information27. Despite the fact that there is high level of awareness, utilization of family planning services is a challenge since only 29% of women actually used the services27. If men are to be compared to women, the latter is more knowledgeable because most of the interventions are women focused.
In Lesotho, a study revealed that almost all the participants 99.2% had knowledge of one family planning method28.
A study carried out by the Nova Scotia Gambia Association (2009) revealed that students concerned about HIV/AIDS in Central River Region of the Gambia was high but other STIs was as low as 2.4% , 17.
For adolescents to lead a healthy, responsible, fulfilling lives and protect themselves from reproductive health problems, they need to be knowledgeable about themselves and need adequate information about the physical, psycho-logical changes that take place during puberty, menstruation, pregnancy and child birth29.
Inadequate knowledge remains a major barrier for adolescents: An in-depth study of four Sub-Saharan African countries found that 60% or more of adolescent men and women believed common misperceptions or had poor knowledge about the prevention of unintended pregnancy and HIV; one-third or more did not know of a source for contraceptives 30.
Among adolescents wanting to avoid pregnancy, the chance of having an unintended pregnancy is much lower if they and their partner use a modern contraceptive rather than a traditional method or no method at all 30.
A study carried out in Ethiopia showed that lack of knowledge of family planning was found to be another important reason for nonuse among women with unmet need. The study revealed that close to one third of the women surveyed had no knowledge of a source for
a method or did not know of a method 31. This showed that knowledge can greatly influence the uptake of family planning services.
Lack of awareness about contraceptive methods may be a reason for not using contraception among Egyptian women32. The study further revealed that Egyptian women did not prefer discussing sexual related problems with men physician due to culture and religion32.
Lack of knowledge of modern contraceptive methods and their mechanism of action have been cited as one of the major reasons for the women’s nonuse of contraception33.
A study on Knowledge, Aattitude and Practice on family planning among married women in Banteay Meanchey, Cambodia revealed that 99.3% among the respondents have heard about contraceptives regardless of educational level and socioeconomic status. Almost all the study participants heard about family planning and knew at least one modern family planning method. Despite the study revealed high knowledge of contraceptives among respondents, the knowledge varies from one method to another. The most known method by the participants were pills and injectable contraceptive, which accounted for 95% and 83% respectively. The other mentioned methods were the condom and IUD 34. The same study showed that most of the participants source of information about family planning was healthcare staff (67.4%),TV (50.7%) radio (35%) and then friends (33%)34.
As study to assess Knowledge, Attitude and Practice of family planning among health care providers in two local governments in Osun State, Nigeria showed that not all health care providers are knowledgeable about family planning method. Less than half knew all the methods most especially the new methods35. This can negatively affect their performance as they will not be able to discuss all methods or opportunities to their clients.
A study in Pakistan showed that the level of knowledge among women was 60%. Most of the knowledgeable were residing in the urban areas of Pakistan36. Adequate knowledge on family planning can be a catalyst for an increased utilization of the services.
A study assessing Knowledge, Attitude and Practice on Family Planning among married women in India shows that all the participants were knowledgeable of FP methods. The findings were higher for female sterilization, followed by use of condom and the least was traditional family planning methods. These findings should be taken with caution because of the fact that the study was within an urban setting with favorable conditions such as health training center, proactive health professionals and other information sharing enhancing facilities37.
A study assessing the awareness and practices of contraceptives was conducted among university students in Botswana and it revealed 58.6% and 59.1% of male and female respectively had good knowledge regarding family38. Furthermore, the study revealed that all the female students (100%) in the study were aware that contraceptives are not 100% effective as compared to 93.7% of the male students38. Finally, the study revealed that 90.6% of females knew that using contraceptives irregular will lead to pregnancy as compared 76.4% of their male counter parts38. The most common known family planning method was the condom 95.6% followed by the contraceptive pills 86.7%.38
A study conducted among students in Brazil revealed that 95% of the study participants were familiar with at least one method of family planning39. It further revealed that the most common method of family planning known by was the male condom39.
A study on knowledge, perception and practice of family planning among staff and students in Niger Delta University, Delta State, Nigeria showed that 84% of the participants had good knowledge of family planning40. The study revealed that 44% believed that family planning help to maintain the desired number of children a couple want, 19.6% said it allow women pursue their career while 18.7% felt it promotes promiscuity40.
Studies revealed that students’ attitude affects their knowledge of sexual and reproductive health 41.Sexual attitude and behaviors of adolescents is significantly sharpened by socio-psychological factors and consequently affect their knowledge of contraception 41. According to them, young adults need better sex education and greater access to family planning services.
A study conducted in Egypt showed that 75% of the women who were nonusers said they intended to use family planning in the future and 81% of the women who had discontinued using family planning intended to use it in the future 32. This shows that most of the women’s attitude towards family planning is very causal.
A student on knowledge, attitude and practice among married women in Banteay Meanchey, Cambodia, indicated that the women preferred to discuss family planning with their neighbors, husbands, doctors and close friends. Less than 10% of respondents had discussed family planning with other family members. A little more than half (52%) of the respondents considered family planning to be concerned with the health of the mother and child while 35% considered family planning to have specific issues on women’s health. Almost all respondents showed positive attitudes in discussing family planning, some respondents disapproved unmarried or single women discussing contraception. 34
A study conducted by the University of Lahore, Pakistan showed that 54% of women have positive attitude and approved family planning36. In a study in India, it was revealed that 83.1% of the participants had a positive attitude towards family planning and out of these about 75% of them were satisfied with the services they have received. This positive attitude towards family planning is reechoed by 5% who are thinking of switching to other types of family planning methods37.
A study among university students in Botswana revealed that about 66% of the study participants revealed that they had engaged in sexual intercourse38. Interestingly, the study showed that the majority of the sexually actively participants were using contraceptive and out of these a quarter were not regularly38.
A survey carried out in China among migrant young adults, showed that 28.0% and14.2% of males and females respectively had pre-marital sex experiences, but only 47.4% of them used condoms, including 16.1% who used condoms half the time and only 4.0% used condoms every time42. The study further revealed that the proportion of study participants’ who actually used condoms was very low due to factors such as perceptions of risk, embarrassment, and cultural aspects of condom use42.
A study in Tanzania among adolescents showed that 59.2% of the study participants were encouraged to use family planning services by their parents compared with 11.7% who were encouraged by their religious leaders. Only 5.6 % of respondents had sought family planning services. The study revealed that females were more likely than males to report contraceptive use 55. 6% and 44.4% respectively. Out of those that reported to have sought for family planning services only 44.4% do so whenever they planned to have sex. The most commonly used contraceptive by males was the condom and females was the injection 27.
A study carried out in Pakistan showed that knowledge doesn’t correlate with practice. The study shows reasonable high awareness level and a very low service uptake, but despite only 17% of married women of reproductive age used modern contraceptives 43.
A study in West Ethiopia on the utilization of family planning showed 78.9% rural and 84.7% of urban rural women had ever used family planning service44. The study further revealed that urban women are more likely to used family planning services than rural women44.
There are many factors that prevent people from utilization of family planning services. Factors like desire for male children, religious reasons and the disapproval of partners45.
Religion and cultural believes plays a critical role in people’s acceptance and use of family planning methods. A study analyzing family planning utilization in India showed that Muslim women have greater opposition to family planning33.
Misconception was one of the reasons for non-use of contraception for fear of infertility. Many women believed that if they use family planning over a long period there are higher chance that when they needed to have children it may be very difficult 33.
A study in Cambodia revealed about 68% of respondents had previously used some modern contraceptive methods and 56% of respondents were using contraception at the time of the study. Among the current users, the majority were pill users (44.6%) followed by those using injection method (38%); and only about 8% of respondents said that they were using condoms. Other methods mentioned were Implants, IUD and female sterilization34.
A study in India showed that 61.3% of the study participants were using one method of family planning. It was also observed that as advance in age, educational level, family size and age of last child had a bearing in the uptake of family planning services37.
A study among staff and students of Niger Delta University on knowledge, perception and practice on family planning showed that 31% of the respondents used condom, 22.9 % used oral pills, 7.6% used the withdrawal method, 4.2% used implants, 3.6% used post-coital pills40. The respondents’ reason for choosing the above family planning methods were safety, reliability and accessibility40.
Many factor are responsible for nonuse of family planning commodities. A study in Cambodia highlighted side effects of the pill and contraceptive injection, and the desire for more children, as the main reasons for not using modern contraceptives34. Some respondents indicated disapproval husbands and relatives, husbands were often working away from home and sex was infrequent so contraceptive use became unnecessary; use of traditional calendar methods; and personal perception among respondents that the women themselves were not at risk of pregnancy34.
A study carried out by University of Lahore, Pakistan showed similar reasons for non-use of family planning services as the study carried out in Cambodia, however the one in Pakistan made emphasis on lack of knowledge about the sources of services36
A study conducted in Ghana revealed that adolescents faced with some barriers in accessing family planning services. These barriers among others were cost of services, societal perceptions of adolescents patronizing FP being spoilt, and adolescents’ fear of healthcare providers being judgmental, discriminatory and may not abide by the principles of privacy and confidentiality during FP service provision to adolescents. Shyness and intimidation were also highlighted to be another barrier to access, resulting from societal and healthcare provider attitudes46.
Factors for non-use of family planning varies from one region to another. A study carried out on factors influencing the uptake of family planning services in Talensi District of Ghana showed that the major constraint of women for non-used of family planning is that they cannot take decisions for themselves without the approval of their husbands, perceived misconceptions about family planning services such as family planning is meant for only married people, harmful to the womb47.
A study conducted in West Ethiopia revealed reasons why some study participants were not utilizing family planning services44. Most of the participants mentioned fertility related reasons such as breastfeeding and not having sex44. Some women were not utilizing family planning because of opposition from husbands or relatives while some it was because of religious reasons44.The study further showed that sometimes potential family planning users preferred not to use more reliable methods due to misconception and concerns about their health which is compounded by lack of adequate knowledge of family planning methods44.
The research will be conducted in two Regional Education Directorates of the Ministry of Basic and Second Education of The Gambia. The two regions are Regions II and IV.
The Gambia is located midway on the bulge of the West Africa coast and stretches over 400 kilometers inland from west to east on either side of the River Gambia, varying in width from about 50 km near the mouth of the river to about 24 km upstream19. The country is surrounded on its three sides by the Republic of Senegal and to the west by the Atlantic Ocean19. The River Gambia runs through the entire length of the country19. The country has a land area of 10,689 square kilometers19.
The preliminary results of the 2013 population census showed that 1.9 million of which women comprises of over half of the country’s population19. About 57% of the population living in the urban areas which makes it more densely populated than the rest of the country19. The country is divided into 5 regions (West Coast, Lower River, Central River, Upper River and North Bank Regions), and two municipalities (City of Banjul and Kanifing Municipality) that constitute the Greater Banjul Area19.
There are five major ethnic groups and approximately 90% of the population are Muslim.19
The education system in The Gambia is a continuum from early childhood development (ECD) to university education with three years of pre-school education, nine years of uninterrupted basic education, three years of secondary education and four years of tertiary and higher education48. It was until 2007 a second ministry of education was created.48. Following the creation of a second ministry, the mandates to deliver education and training have now been segregated between the two ministries of education, namely: The Ministry of Basic and Secondary Education (MoBSE) and The Ministry of Higher Education, Research, Science and Technology (MoHERST)48.
The study will be conducted in Region II and IV.
Region II Education Directorate covers the West Coast Region. The region spans from Kartong to Kanlagi. It has a population of 699, 706 and an annual growth rate of 6.1%12. The male population is slightly higher than that of the females; 50.2% for male and the rest females12. The region has 1 hospital, 2 major health centre, 8 minor health centers and private clinics49. Region II has one hundred and seventy secondary schools and a student population of 54,69850.
Region IV Education Directorate covers Lower River Region. The region stretches from Jattaba to Pakaliba. The region has a population of 82,361 and the population distribution of males and females is 48.2% and 51.8% respectively. The region has 1 major health center, and 4 minor health centers49. Region IV spans from Jataba to Pakaliba. It has 28 secondary schools and a student population of 564950.
The study will be conducted in two different Regional Educational Directorates. The two directorates are Regions II&IV. Region II in this study will be considered urban area while Region IV as rural.
Regional Education Directorate II and IV were randomly selected using simple random sampling technique. Region II representing the urban while Region IV rural.
According to the Ministry of Basic and Secondary Education in The Gambia, there are 128 Juniors Secondary School Students in the two regions (117 in WCR & 11 LRR) and 60 senior secondary schools (53 in WCR & 7 in LRR). The total number of students in the junior secondary schools is 40,550 and 19,797 in the senior secondary schools50.
For representativeness, a proportional sampling will be conducted in all the schools for the purpose of this study.
A descriptive cross-sectional study design will be conducted to assess the KAP on Family Planning of Secondary School Students and observe whether geographical location has an effect on the KAP in Region II&IV Education Directorates of the Gambia.
Self-administered questionnaire and FGD will be used to collect with the aid of trained research assistants.
Focus Group Discussions (FGDs) qualitative method will used to compliment and validate the quantitative data collection. Twelve FGD sessions will be held in school selected for the study.
A focus-group session is an in-depth discussion in which a small number of people (usually 8-12) from the target population discuss topics that are of importance for a particular study or project51. It is advisable the participants for the FGD are homogeneous with respect to characteristics 51. The advantage of this method is that it method that determines attitudes, experiences, perceptions, and knowledge on a wide range of topics in many fields of endeavor. Focus groups lead to the voicing of attitudes and insights not readily attain able from other qualitative forms of data collection like the individual interview and the weaknesses of this method are that the effect of group dynamic can affect the interaction of the participants 52. Some of the participants may dominate the discussion while others may not participate in the discussion which may affect the findings, as the reflections and opinions of those not taking part will not be captured. Another weakness of the method is the social context in which it is conducted, because participants may not feel comfortable to openly talk about their experiences or opinions on the issue being discussed without being judged or ridiculed by other members of the group. The presence of some members in the group may intimidate some participants and they may conform to the dominant ideas that are presented 52.
The study will take five months that is from December 2016 to May 2017. Refer to the Gantts Chart in the appendix.
Sample size will be calculated using the formula;
p=the proportion of research participants with adequate knowledge, attitude and practice (50% is assumed here since there is no known prevalence)
q=1-p
d=the degree of accuracy desired set at 0.05. Thus the minimum sample size with a design effect will be 769. Due to the sensitivity of the questions in the data collection tool, a 10% non-respondents rate will be considered, hence a total of 846 students will constitute the study sample.
A multi-stage sampling technique will be used to recruit study participants for this study. First, a simple random sampling method will be used to select two regional education directorates from the six education directorates in The Gambia. In the second stage, in each of the selected education directorates schools will be randomly selected for the study. A total of twelve secondary school will be selected. The third will also a simple random sampling to identify the classes/grades that will be recruited for the study. Grade 7 to Grade 12 students will be recruited for the study.
A sample of 846 students will be recruited in the study out a study population of 60347 Secondary School Students. A proportional sampling will be conducted to ensure representation of 10 secondary schools that will be selected. Out of the 846, 90% of sample population will be allocated to Region II Education Directorate while the rest for Region IV Education Directorate. The list of the schools in the study and the number of students will be accessed by MoBSE.
The inclusion criterion is such that only students enrolled in the selected schools irrespective of age and sex.
The study excludes students that are absent on the day of data collection.
The researcher with the help of the supervisor(s) will develop a questionnaire based on research objectives. The questionnaire will be peer reviewed (face validity) by the supervisor(s) and experts in family planning. The developed questionnaire will be pretested for reliability and validity at a different regional educational directorate.
The outcome of the questionnaire will greatly depend on how well the research participants understand the questions and their understanding may be affected by language skills, education and culture 53 . Pre-testing starts of reviewing and revising questions process53. The aim of pre-testing is to evaluate whether respondents interpret questions in a consistent manner, as intended by the investigator, and to judge the appropriateness of each included question,53
A total of 100 participants will be recruited for this purpose. The length of each of the 30 interviews would be timed. Ideally the length of each interview will not take more than 30 minutes.
After the pretesting of the questionnaire, SPSS package Version 20 will be used to statistically test the validity and reliability of the questionnaire.
The Questionnaire in Appendix 1 will be used to collect data on the above mentioned variables. A Focus Group Discussion checklist will be used to collect the more information on the knowledge, attitude and practice. All tools will be pre-tested in a different regional education directorate for readability, understanding, and clarity.
The selected data collectors will be fluent in the local dialects in case there is a need to translate for the understanding of the students and during training they will translate the questionnaire back and forth for understanding and clarity.
Study Permission – will be sought from Ethics Committee, Science Committee, the Ministry of Basic and Secondary Education, Regional Education Directors and the School principals, (see appropriate Appendix for each). The data collection will proceed with the permission of all the above, and the students are free to withdraw their permission at any time of the study if they so wish.
Data Collection – First the schools will be informed of the purpose of the study. A school day will be used at each school setting, which is between Monday and Friday. 12 data collectors will be trained for one week on the purpose of the study, questionnaire administration, and conduct of FGD. The research assistant are going to be Community Health Nurses (CHNs) with at least two years post training. When assured of a complete understanding and mastery of the tools, then the study proper will start at the selected schools. The research assistants who will be recruited for the study will qualified circuit community health nurses with at least four years post training work experience. The community health nurse cadre is the second level nurses in the Gambia. They have two years extensive training on nursing procedures. The reason of recruiting this cadre is that they are very good in collecting very sensitive community information.
At least a day will be spent at each school, where semi-structured questionnaires will be administered to the subjects, and two FGDs conducted. The questionnaires will be on knowledge, attitude and practice on family planning.
Data Management – since the data will be mostly coded, all will be entered after checking for errors. Ten percent of randomly selected data will be validated by double entry. The data will be kept in a locked safe and individual students will not be traced by names, because they can only be identified by codes known to the research team only.
Data processing and analysis will be done using the Statistical Package for Social Sciences (SPSS) Version 20.0 for windows program. Descriptive statistics such as frequencies, percentage, and appropriate graphic presentation besides measures of central tendency and measures of dispersion will be used for Univariate analysis. Bivariate analysis will be used to analyze some of the variables.
The FGD data will be transcript and analyze using theme.
This study will be subjected to the approval of the Ethics Review Board of University of Benin & University of Benin Teaching Hospital. Approval will also be sought from the Joint Gambia Government –MRC Ethics Committee in The Gambia. The study targets are secondary school students so their assent as well as their school principals’ consent will be sought with adequate information, after securing the approval of the Ministry of Basic and Secondary Education (MoBSE).
This study will compare the knowledge, attitude and practice on family planning among secondary school students in Region II&IV Education Directorates. Even though a cross-sectional study cannot confer causality, it is the design of choice here because it is quick, economical, and the study is a prevalence study that does not require follow up.
Strength of the study is its large sample size and it is including students of many schools.
Due to the sensitivity of the study subject, some study participants may feel ashamed to raise their hands when they need clarifications. This can cause them not to fill all parts of the questionnaire. Therefore to reduce nonresponse rate an additional 10% will be increased on the sample size. This may limit the generalization of the findings.
The other strength of the study is the use of FGD. FGD will be used to validate the data collection using the questionnaire.
STUDY TIMELINE
The study hopes to take this long to be accomplished. See Table below for summary of the study timeline.
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