University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA BARRIERS TO THE USE OF CONTRACEPTIVES AMONG MARRIED WOMEN IN PAGA, UPPER EAST REGION, GHANA BY NAFISATU SULEMANA STUDENT ID-10508460 THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT FOR THE AWARD OF THE MASTER OF PUBLIC HEALTH DEGREE. NOVEMBER, 2015 University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Nafisatu Sulemana, declare that except for the other people’s investigations which have been duly acknowledged, this work is the result of my own original research, and that this dissertation, either in whole or in part has not been presented elsewhere for another degree. …………………………… ……………………… Nafisatu Sulemana Date (Student) …………………………………. ………………………… Dr. Ayaga .A. Bawah Date (Supervisor) University of Ghana http://ugspace.ug.edu.gh DEDICATION This work is dedicated to my lovely parents; Mr. and Mrs Sulemana. They are the best parents one can have in the world. They always give me the desire to excel. Thank you Nma and Baba. I also dedicate this work to my uncles and all my siblings for their support, understanding and encouragement. A special dedication to my late brother Mahamadu Saani Sulemana. R.I.P ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT My profound gratitude goes to Almighty Allah for making it possible for me to go through this programme successfully. My heart-felt thanks goes to Dr. Ayaga A. Bawah for supervising my work. I am grateful and appreciate his advice, essential and fruitful comments, patience and guidance throughout my research period. My sincere thanks also goes to Professor Augustine Ankomah Head of Department of Population, Family and Reproductive Health, School of Public Health, Legon, for his generous help and advice. You are really a wonderful father. To all my programme mates, especially Ayo-Maria Gregory Olofinkua, Ogunlade Ayo, and Osa Olayemi, who were instrumental to the successful completion of my MPH degree, I express my heart-felt appreciation for all your efforts. I am also grateful to all who helped in my data collection process not forgetting my participants who made this work a possibility. iii University of Ghana http://ugspace.ug.edu.gh ABSTRACT Background: Contraceptive use is an essential and highly beneficial component of family planning. Most people across the globe know at least one method of contraceptive but its use is very low. It is therefore necessary to encourage its use especially among married women of child-bearing age as it is beneficial to the welfare of both mothers and their children. The study sought to identify the barriers to contraceptives use among married women in Paga. Methodology: This was a descriptive cross-sectional study conducted among 216 married women aged 15-49 years, in Paga, a community in the Upper East region of Ghana. Systematic sampling with a random start was employed in recruiting the participants, and a structured questionnaire was used to gather data on the demographic characteristics and barriers to contraceptive use among the participants. Data was analysed using frequencies, chi-square tests and logistic regressions on STATA version 13.0. Results: The study found knowledge of any method of contraceptives to be high (81.02%) but current use was much lower at 18.98%. In addition, depo/injectables (9.26%) and the pill (4.63%) were the most used methods. The major barriers to non- use and continued use were the fear of side effects (35.16%), infertility/difficulty in getting pregnant (21.98%), difficulty in getting preferred methods (20.88%) and the desire to have more children (27.27%). In addition, the age and education of participants were found to be significant predictors of contraceptive use. Keywords: Contraceptives, family planning, barriers, Health Belief Model, Paga, Ghana. iv University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION ......................................................................................................... i DEDICATION .............................................................................................................. ii ACKNOWLEDGEMENT ........................................................................................... iii ABSTRACT ................................................................................................................ iv TABLE OF CONTENTS ............................................................................................ v LIST OF TABLES .................................................................................................... ix LIST OF FIGURES .................................................................................................... x LIST OF ABBREVIATIONS ...................................................................................... xi DEFINITION OF TERMS ........................................................................................ xiii CHAPTER ONE ........................................................................................................ 1 INTRODUCTION ..................................................................................................... 1 1.1 Background ................................................................................................... 1 1.2 Problem Statement ........................................................................................ 3 1.3 Justification of the Study ............................................................................... 5 1.4 Conceptual Framework ................................................................................. 6 1.5 Objectives of the Study ................................................................................. 9 1.5.1 General Objective .................................................................................. 9 1.5.2 Specific Objectives ................................................................................ 9 CHAPTER TWO ....................................................................................................... 10 LITERATURE REVIEW .......................................................................................... 10 v University of Ghana http://ugspace.ug.edu.gh 2.2 History of Contraceptives.............................................................................. 10 2.3 Prevalence of contraceptives ......................................................................... 11 2.4 Knowledge of contraceptives methods ......................................................... 13 2.4.1 Methods of contraception ...................................................................... 14 2.4.2 Hormonal method .................................................................................. 15 2.4.3 Intra-Uterine Device (IUD).................................................................... 16 2.4.4 Natural/Traditional methods ................................................................. 17 2.5 Barriers to contraceptive use ......................................................................... 18 CHAPTER THREE ................................................................................................... 24 METHODOLOGY .................................................................................................... 24 3.1 Study Design ................................................................................................. 24 3.2 Study Area ..................................................................................................... 24 3.3 Variables........................................................................................................ 25 3.3.1 Dependent Variable ............................................................................... 25 3.4 Study population ........................................................................................... 26 3.5 Sampling........................................................................................................ 27 3.5.1 Sample size estimation ................................................................................ 27 3.5.2 Sampling Technique .............................................................................. 28 3.6 Data collection............................................................................................... 29 3.6.1 Data collection/techniques ..................................................................... 29 3.6.2 Pre-testing .................................................................................................... 29 vi University of Ghana http://ugspace.ug.edu.gh 3.7 Data analysis ................................................................................................. 30 3.7.1 Data processing and cleaning ...................................................................... 30 3.7.2 Data analysis process ............................................................................. 30 3.8 Ethical considerations ................................................................................... 31 3.10 Data storage and usage .................................................................................. 32 3.11 Conflict of interest ..................................................................................... 33 3.12 Dissemination of findings ............................................................................. 33 CHAPTER FOUR ...................................................................................................... 34 RESULTS .................................................................................................................. 34 4.1 Background Characteristics of Participants .................................................. 34 4.2 Knowledge, Use and Sources of Contraceptives .......................................... 36 4.3 Knowledge and use of contraceptives among Participants ........................... 38 4.4 Factors that are likely to affect contraceptives use ....................................... 39 4.5 Barriers to contraceptives use ....................................................................... 42 4.6 Misconceptions about contraceptives............................................................ 44 4.7 Perceived susceptibility and severity to contraceptive use ........................... 45 4.8 Associations between Participants’ characteristics with current use and knowledge of contraceptives .................................................................................... 47 4.9 Results of regression analysis ....................................................................... 50 CHAPTER FIVE ....................................................................................................... 53 DISCUSSION ............................................................................................................ 53 5.1 Introduction ................................................................................................... 53 vii University of Ghana http://ugspace.ug.edu.gh 5.2 Limitations of the study................................................................................. 63 CHAPTER SIX .......................................................................................................... 65 CONCLUSIONS AND RECOMMENDATIONS .................................................... 65 6.1 Conclusions ................................................................................................... 65 6.2 Recommendations ......................................................................................... 66 REFERENCES .......................................................................................................... 67 APPENDIX 1 ............................................................................................................. 76 INFORMED CONSENT FORM ............................................................................. 76 APPENDIX 2 ............................................................................................................. 78 QUESTIONNAIRE FOR RESEARCH ON BARRIERS TO CONTRACEPTIVES USE AMONG MARRIED WOMEN AGED 15-49 IN PAGA ............................... 78 viii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 4. 1 : Socio-demographic characteristics of Participants ................................... 36 Table 4. 2: Knowledge, use and sources of information on contraceptives ............... 38 Table 4. 3: Factors that are likely to affect contraceptive use among Participants ..... 41 Table 4. 4: Barriers to the use of contraceptives .......................................................... 43 Table 4. 5: Barriers to the use of contraceptives ......................................................... 45 Table 4. 6: Perceived susceptibility and severity to contraceptive use ........................ 46 Table 4. 7: Associations between Participants’ characteristics with current use and knowledge of contraceptives ........................................................................................ 49 Table 4. 8: Results of regression analysis .................................................................... 52 ix University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1. 1: Conceptual Framework (Adapted from Hochbaum, 1958) ...................... 7 Figure 3. 1: Map of Kasena Nankana West District showing the study area; Paga .... 25 Figure 4. 1: Knowledge and use of contraceptives among Participants (modern methods). ...................................................................................................................... 39 x University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS ACOG American College of Obstetrics and Gynaecology AIDS Acquired Immune Deficiency Syndrome AOR Adjusted Odds Ratio CDC Centre for Disease Control CI Confidence Interval COCs Combined Oral Contraceptives CPR Contraceptives Prevalence Rate Cu-IUD Copper-bearing Intra-uterine Device DHS Demographic Health Survey FP Family Planning FSH Follicle Stimulating Hormone (FSH) GDHS Ghana Demographic and Health Survey GNPP Ghana National Population Policy GSS Ghana Statistical Service HBM Health Belief Model HIV Human Immune Virus IRD International Relief and Development IUD Intra-Uterine Device xi University of Ghana http://ugspace.ug.edu.gh LH Luteinizing Hormone LNG-IUS Levonorgestrel-releasing Intrauterine System MDGs Millennium Development Goals OCs Oral Contraceptives OR Odds Ratio PPAG Planned Parenthood Association of Ghana PPFA Planned Parenthood Federation of America PRB Population Reference Bureau STIs Sexual Transmitted Infections TFR Total Fertility Rate UCC University of Cape Coast UK United Kingdom UN United Nations US United States USAID Unites States Agency for International Development WHO World Health Organization xii University of Ghana http://ugspace.ug.edu.gh DEFINITION OF TERMS Total Fertility Rate (TFR): The average number of children a woman would have in her lifetime, assuming the current age-specific birth rates. Contraceptive Prevalence Rate (CPR): It is the percentage of women who are currently using, or whose sexual partner is currently using, at least one method of contraception, regardless of the method used. Contraceptives: Contraceptives refers to the various devices, drugs, agents, sexual practices, or surgical procedures used in preventing conception or impregnation (pregnancy). Combined Oral contraceptives: It is a birth control method that includes a combination of an estrogen (estradiol) and a progestogen (progestin). Barrier methods of contraceptives: These are contraceptive methods that work by creating a physical barrier between sperm and egg cells so that fertilization cannot occur. Unmet need for family planning: The percentage of women of reproductive age, either married or in a union, who want to stop or delay childbearing but are not using any method of contraception for family planning. Odds ratio: An odds ratio (OR) is a measure of association between an exposure and an outcome that informs on the odds of an outcome occurring, given a predictor occurring first. Hormonal methods: Hormonal contraceptives are birth control methods which regulate the endocrine system to control fertility. Cue to action: Motivational factors that push an individual to take up a particular health seeking behaviour. xiii University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1 Background The population of the world has increased from 6.916 billion in 2013 to a current population of 7.2 billion in 2014 (Population Reference Bureau [PRB], 2014); much of the growth has occurred in the developing countries which have a population of 6 billion compared to a smaller 1.2 billion in the more developed countries (PRB, 2014). This growth is due to a global Total Fertility Rate (TFR) of 2.5 child per woman, an average rate which spans a wide variation from as low as 1.1 child per woman in Taiwan to as high as 7.4 child per woman in Niger (PRB, 2014; United Nations, 2014). In addition, the rate in Niger is indicative of the high TFR in developing countries, especially in sub-Saharan Africa, where the population has been projected increase by as much as 5 times between 2014 and 2100 (United Nations, 2014). As at 2010, the average TFR for sub-Saharan Africa was 5.1 births per woman, and the UN projects that the population of sub-Saharan Africa will increase from 0.86 billion in 2010 to 1.96 billion in 2050 (Bongaarts & Casterline, 2013). The TFR in Ghana remains high, which according to the 2014 Ghana demographic and health survey currently stands at 4.2 births per woman. This has given rise to an unusual and rapid growth in population, contributing to environmental degradation, poverty and a declining quality of life for the majority of the people (Ghana Statistical Service, 2015). One of the most effective ways of regulating fertility is through family planning programmes by using contraceptives in communities all over Africa (Roudi-Fahimi, 1 University of Ghana http://ugspace.ug.edu.gh 2003). Contraception is one of the components of Family Planning (FP) and a key determinant of fertility in Bongaarts’ proximate determinants of fertility (Bongaarts, 1978). Contraceptives benefit the health and wellbeing of women, men, children, families, and communities at large, because high fertility rates coupled with inadequate spacing between births, can lead to high maternal and infant mortality (Haddad et al., 2014; Mekonnen & Worku, 2011). Efforts to achieve the Millennium Development Goals 4 and 5, which aims at reducing infant and maternal mortality globally, led to the WHO report which revealed that sub-Saharan Africa alone is responsible for 62% (179,000) of global maternal deaths, and the region also reports an infant mortality rate of 98 deaths per 1,000 live births (World Health Organization, 2014). With effective contraceptive use, this statistics can improve, and the chances of meeting the MDGs by the target date of 2015 becomes brighter. The relatively high fertility in Ghana (4.2) can be attributed to low levels of contraceptive use, which is reflected in the current national contraceptive prevalence rate of 27% (Ghana Statistical Service, 2009). Contraceptives use is not just important because of how it affects fertility but also because of its health implications to the mother and the child. To fully understand the concept of contraceptive use, it is necessary to explore the very idea of contraceptives. Contraceptives are devices, drugs, agents, sexual practices or surgical procedures used to plan and prevent pregnancy, limit the number of children given birth to, and control population growth (Meka, Okwara, & Meka, 2013). Contraceptives prevent pregnancy by interrupting the natural process of ovulation, fertilization, and implantation (Trussell, Raymond, & Cleland, 2014). Apart from its 2 University of Ghana http://ugspace.ug.edu.gh major purpose of birth control, contraceptives also help to prevent the spread of sexually transmitted diseases and infections (Ahmed, Li, Liu, & Tsui, 2012). Contraceptives exist in various forms, and they act differently on the reproductive process: some modern contraceptives includes the condom (male and female), pills, injectable, Intra-Uterine Device (IUD), Tubal ligation and Implants (Centers for Disease Control and Prevention, 2014). In developing countries, about 818 million of sexually active women in their reproductive age (15-49 years) want to avoid pregnancy and delay child bearing for at least two years or want to stop pregnancy and limit their family size. However, about 140 million (17%) of those women are not using any method of family planning, while 75 million (9%) are using the less effective traditional methods (Darroch, Sedgh, & Ball, 2011). Although there is a high level of knowledge of contraceptives (in Ghana, it is 99% for males and 98% for females), the effective use of contraceptives is still not as widespread as it should be, because various barriers prevent its use (Darroch, et al., 2011). Asamoah, Agardh and Ostergren (2013) identified factors that affect contraceptive use in Ghana and these include; national factors, regional factors, community, kinship and household and individual factors (Asamoah, Agardh, & Östergren, 2013). Other barriers hindering access to contraceptives for many women include the refusal of pharmacies and chemical drug stores to carry and/or sell, and lack of insurance covering its cost. 1.2 Problem Statement Although Ghana was one of the first sub-Saharan African countries to adopt a National Population Policy (NPP) in 1969, it has consistently failed to reach some its policy 3 University of Ghana http://ugspace.ug.edu.gh goals. These goals were to reduce the Total Fertility Rate (TFR) to 3.0 by the year 2020, achieve a contraceptive prevalence rate (CPR) of 20% for modern family planning methods by the year 2020 and reduce the annual population growth rate to 1.5% by the year 2020 (National Population Council., 1994). The failure to achieve all of these targets is not due to a rejection of family planning, as an increasing number of married women (from 23% in 1988 to 35% in 2008) have the desire to limit child birth (Ghana Statistical Service, 2009). Instead, the desires of many women to control their birth are not being fulfilled, leading to an unmet need for family planning. The unmet need for family planning among currently married women is 30% (this is a decrease from the figures of 35% reported in the 2008 GDHS survey) (GSS, 2015). Overall, the total demand for contraceptives among married women is 57% of which only 26.7% of the demand has been met. This means that the contraceptive needs of 53% of all married women in Ghana who expressed the need has not been met, which is a dismal state of events that should be addressed. In addition, while the increased use of contraceptives (from 13% in 1988 to 25% in 2003 and 27% in 2014) has translated to a corresponding decrease in Ghana’s TFR from 6.4 in 1988 to 4.2 in 2014, the rate of growth in contraceptive use remains poor (GSS, 1999; 2015). The TFR of the Upper East region is also high, falling from 6.8 in 1988 to 4.1 in 2008, which is slightly higher than the current national figure of 4.2 (GSS, 1999; 2009; 2015). Although knowledge of at least one method of contraceptive (99%) is high in Ghana, this has not led to an increase in use. The various policies, actions and programs implemented to increase family planning application organised by the Ministry of Health, and development/non-profits organizations like the Planned Parenthood Association of Ghana (PPAG), USAID and Marie Stopes Ghana have also not yielded 4 University of Ghana http://ugspace.ug.edu.gh impressive results (Solo, Odonkor, Pile, & Wickstrom, 2005). As such, it is clear that there are deep-rooted barriers worth investigating, which are impeding the wider use of contraceptives. Studies have been conducted on contraceptive prevalence among women in Navrongo, but these studies did not necessarily look at the barriers to contraceptives use among married women. Some of these studies include: “The impact of the Navrongo Project on Contraceptive Knowledge and Use, Reproductive Preferences, and Fertility" (Debpuur et al., 2002) “Intention to use contraceptive and subsequent contraceptive behaviour” (Maurice, 2007) “Contraceptive use among at risk women in Metropolitan area in Ghana” (Opoku, 2010), “Contraceptives use by women in Accra, Ghana: Results from the 2003 Accra Women’s Health Survey (Adanu et al., 2009). This shows that to increase contraceptive use and effectively reduce the TFR of Ghana to replacement levels, there is the need to identify and explore the barriers to contraceptives use. Such necessity forms the basis for the research question of this study; “What are the barriers to contraceptives use among married women in Paga?” Answering this question will help to bridge the knowledge gap in knowing the contribution that difficulties in assessing contraceptives among married women has to the higher Total Fertility Rate of the Upper East Region. 1.3 Justification of the Study This study would help identify the barriers to the use of contraceptives among married women aged 15-49 years in Paga. Findings from the study would help policymakers in developing new approaches for increasing the use of contraceptives not only among married women in Paga, but also across Ghana. The study will also help to generate 5 University of Ghana http://ugspace.ug.edu.gh new ideas for reducing women’s negative perceptions and attitudes towards use of contraceptives. Recommendations that would be made in this study may play some role in improving effective use of contraceptives and family planning services, and thereby contribute towards reaching the millennium development goals by decreasing maternal and child mortality. 1.4 Conceptual Framework The study adopted the Health Belief Model which was originally propounded by Hochbaum, Rosenstock and Kegels in the 1950s. The model was developed by social psychologists Hochbaum, Rosenstock and Kegels working at the US public service to explain why many people did not take part in public health programs such as TB or cervical cancer screening (Hochbaum, 1958). The Health Belief Model is a psychological model that seeks to explain and predict the health seeking behaviour of individuals by focusing on their attitudes and beliefs. The model has been used to explain long-term and short-term health seeking behaviours such as explaining different reactions to symptoms and to explain variations in adherence to treatment. It has also been used to explain health seeking behaviours like risky sexual behaviours, HIV/AIDs and contraceptives use to prevent unwanted pregnancies and promote the health of the woman. The health belief model (HBM) is based on the following core assumptions; a married woman will use contraceptives if she thinks it would be of benefit to her health (i.e. eliminate a negative health outcome like maternal morbidity or mortality). 6 University of Ghana http://ugspace.ug.edu.gh Figure 1. 1: Conceptual Framework (Adapted from Hochbaum, 1958) In the Health belief model, the key variables are the possibility that a person will take a preventive behaviour if influenced by their subjective weighing of the costs and benefits of the action. The elements of this perception include; perceived susceptibility, perceived benefits, perceived severity, perceived barriers, cues to action, and self- efficacy (Rosenstock, Strecher, & Becker, 1988). Although the model comprises of six variables, this study adopted four constructs which include; perceived susceptibility, perceived severity, perceived barriers, cues to action and add a fifth variable of misconceptions about contraceptives was added to it. Perceived benefits and self- efficacy was not used because the study does not aim to look at the benefits to contraceptives among the participants, neither does it aim at checking the efficacy of the participants who use contraceptives. 7 University of Ghana http://ugspace.ug.edu.gh Perceived susceptibility seeks to find out if an individual consider him/herself at risk of a particular health outcome. For this study, perceived susceptibility was viewed from the perspective of a married woman who considers herself at risk of getting unwanted pregnancy or maternal morbidity or mortality. Perceived severity refers to the feelings of an individual concerning the seriousness of contracting an illness or of leaving it untreated (including evaluations of both medical/ clinical consequences and possible social consequences). For the purpose of this study, perceived severity refers to perception of need of contraceptives by a married woman. If she feels there is no need for contraceptives, she is assumed to consider the consequences of not using contraceptives as not serious. But if she feels there is a need for contraceptives, and that contraceptives are needful to among many things, prevent unwanted pregnancies and its adverse effects, she has acknowledged the severity of not using and will resort to the use of contraceptives. Cue to action refers to the motivational factors that push an individual to take up a particular health seeking behaviour. In the case of this study, cue to action is considered as the factors that are likely to affect contraceptives use. Some of these included parity and the ability of a married woman to communicate with her partner. Perceived barriers are the perceptions of potential negative consequences that may result from taking particular health actions, including physical, psychological, and financial demands. In this study, perceived barriers are the factors that impede or prevent a married woman in Paga from using contraceptives (like; cost of contraceptives and fear of side effects) and how these barriers can be reduced to promote their health. 8 University of Ghana http://ugspace.ug.edu.gh Misconceptions about contraceptives refers to the incorrect beliefs about contraceptives in the society such as contraceptives causes’ infertility. If the married woman is able to deal with these misconceptions, she will resort to the use of contraceptives. 1.5 Objectives of the Study 1.5.1 General Objective To determine the barriers affecting the use of contraceptives among married women in Paga 1.5.2 Specific Objectives 1. To identify contraceptives prevalence 2. To assess knowledge level of contraceptives among married women in Paga 3. To identify barriers to the use of contraceptives 1.6. Research questions 1. What are the barriers to contraceptives use among married women in Paga? 2. What is the level of knowledge of contraceptives among married women in Paga? 3. What is the prevalence rate of contraceptives among married women in Paga? 9 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.1 Introduction This chapter is a review of literature in relation to the topic ‘Barriers to the use of contraceptives among married women in Paga’. The literature was organised in relation to history of contraceptives, knowledge of contraceptive methods, barriers to contraceptive use and prevalence of contraceptives among married women. Information for the review was in the form of journals, books, online articles, newspaper articles all obtained from various offline and online sources such as Google Scholar, HINARI, PUBMED, Elsevier, ScienceDirect, OnlineWiley Oxford Journals, SCOPUS, SAGEPUB, Taylor and Francis and other databases. 2.2 History of Contraceptives Historically, the human race has sought to control births using methods such as abstinence, withdrawal, and abortion which were sanctioned by many ancient societies. Also, barrier methods such as vaginal sponges and cervical caps were also used in the Middle East including ancient Egypt several thousand years before the common era (Planned Parenthood Federation of America [PPFA], 2012). This shows that the need for contraceptives has always been present and a variety of methods such as ‘coitus interruptus’ (the oldest traditional method) were used (PPFA, 2012). More so, apart from a wide variety of superstitious methods (such as walking three times around the spot where a pregnant wolf had urinated), the ancient Egyptians developed penis protectors both as a health necessity and a status symbol, and Chinese women drank lead and mercury to control fertility, which often resulted in sterility or death (PPFA, 2012). 10 University of Ghana http://ugspace.ug.edu.gh In the mid-19th century, the industrial revolution ushered in the development of chemical contraceptives in the UK, alongside other methods like diaphragms and cervico-uterine stems which prevented conception and implantation (Family Planning Association UK., 2010). The 20th century witnessed a phenomenal increase in the development, and use of contraceptives, as a wide variety of clinically safe methods became much more widely available for popular use (Seltzer, 2002). 2.3 Prevalence of contraceptives Globally, as part of the plan to achieve the Millennium Development goal 5, which is to improve maternal health, governments have committed themselves to achieve, by 2015, universal access to reproductive health (Target 5.B) (Kirtley, Murray, & Kennedy, 2009). Two indicators to help assess the achievement of this goal are contraceptive prevalence (indicator 5.3) and unmet need for family planning (indicator 5.6) (Kirtley et al., 2009). In 2011, an estimated 63% of women worldwide who were married or in a union were using a contraceptive method, though prevalence of contraceptive levels differed widely across continents and sub-regions. Contraceptive prevalence was lowest in Africa (31%), less than 25% in Central and West Africa, and was 70% or higher in Europe, Latin America and the Caribbean and Northern America (United Nations, 2013). Furthermore, in terms of methods, modern methods of contraception are the most common methods worldwide among women of reproductive age between the ages of 15-49 years who are in a marital union (nine in ten contraceptive users worldwide relied on a modern method of contraception), with female sterilization and IUDs being the most common at 19% and 14% prevalence respectively, while oral contraceptives at 11 University of Ghana http://ugspace.ug.edu.gh 9% comes in as the third most common method (Biddlecom & Kantorova, 2013; United Nations, 2013). In addition, the most commonly used modern methods in the developing world are the pill, and depo/injectables (Khan, Mishra, Arnold, & Abderrahim, 2007). A study by Pacqué-Margolis, Cox, and Puckett, Schaefer (2013), showed that sub- Saharan Africa has a contraceptive prevalence rate of 19% which cuts across the prevalence rates of many countries, ranging from 1% in Somalia to 60% in South Africa (Pacqué-Margolis, Cox, Puckett, & Schaefer, 2013). However, in West Africa, it is estimated that approximately 13% of married women use some form of family planning. The most commonly used methods include hormonal contraceptives; the pill and injectable. Traditional family planning methods, including periodic abstinence and withdrawal, are in second place (Gribble, 2008). In Ghana, the contraceptive prevalence rate is 27% with modern methods use among married women aged 15 to 49 years being 22% (GSS, 2015). Also, the prevalence for ever use of contraceptives according to the 2008 GDHS is 60% (GSS, 2009). Unmet need for family planning is defined as the percentage of women of reproductive age, either married or in a union, who have an unmet need for family planning. Women with unmet need are those who want to stop or delay childbearing but are not using any method of contraception (Sedgh & Hussain, 2014). The total demand for family planning defined as the sum of unmet need and current contraceptive use is on average 44% in sub-Saharan Africa, compared with a 70% in Asia, the Near East and North Africa, and Latin America and the Caribbean (Ashford, 2003). In developing countries, 82% of women are faced with an unmet need for family planning. The 2014 Ghana demographic and health survey (GDHS) also reported a 12 University of Ghana http://ugspace.ug.edu.gh 30% unmet need among currently married women in Ghana which represents a 5% decrease from the 2008 GDHS of 35% unmet need (GSS, 2009; 2015). According to a study by Guttmacher Institute (2010) in the Philippines, 22% of married women who were still fecund did not want to have a child in the next two years or at all, and yet they were not using any contraceptive method (Guttmacher Institute, 2010). Reasons stated for this unmet need in the Philippines were health related ones and the fear of side effects, with 44% of women reporting to the latter reason which represented a 3% increase from the findings of similar studies in 2003 (Guttmacher Institute, 2010). 2.4 Knowledge of contraceptives methods Determining the use of any contraceptive method is the knowledge possessed about it (Sedgh, Hussain, Bankole, & Singh, 2007). Research has shown that globally, there is a high saturation of knowledge about contraceptive methods, with sub-Saharan Africa nations averaging 85% in terms of national population proportion who have knowledge of at least one contraceptive method (Sedgh et al., 2007; United States Agency for International Development, 2007). A study by Apanga and Adam (2015) had similar findings as they reported that in Talensi district of Upper East region, knowledge of family planning was high (89%) (Apanga & Adam, 2015). In Ghana, the level of knowledge of at least one contraceptive method is even higher with the 2008 GDHS report stating that 98% of all women and 99% of all men know at least one method of contraception (GSS, 2009). This knowledge shows some considerable variability across different population demographics, with those in the rural areas knowing less than those in urban settings (Apanga & Adam, 2015). According to the 2008 GDHS report also, those with a higher level of education have more knowledge about contraceptives than those with a lower 13 University of Ghana http://ugspace.ug.edu.gh level of knowledge (GSS, 2009). This confirms studies conducted by Heinemann et al. (2005) around the world, Myer et al. (2007) in South Africa and Andalón, Williams and Grossman (2014) in the US, that education status is a predictor of the knowledge of contraceptive methods (Andalón, Williams, & Grossman, 2014; Heinemann, Saad, Wiesemes, White, & Heinemann, 2005; Myer, Mlobeli, Cooper, Smit, & Morroni, 2007). A study by Aryeetey et al. (2010) in the Ga East district of Greater Accra among women of ages 15-49 years further corroborates the association of education and knowledge (Aryeetey, Kotoh, & Hindin, 2011). The authors found that knowledge of any modern method of contraceptives was near universal at 99.7% of all participants, with the number of modern methods known to women increased with increasing level of education (Aryeetey et al., 2011). Other determinants of knowledge were age and income. However, it is presumed that knowledge directly translates to use (Frost, Lindberg, & Finer, 2012). 2.4.1 Methods of contraception The practice of contraception is a growing necessity for women and the larger society; however, such practice is based on an awareness of the various methods of contraception available for use. As such, it is needful to conduct a brief exploration of the methods of contraception and their peculiarities. According to Weeks (2002) cited in Adongo, Phillips, Tapsoba, Stone and Tabong (2014), methods of contraception can be grouped into barrier, chemical, natural or surgical (Adongo, Phillips, Tapsoba, Stone, & Tabong, 2014). For the purpose of this study however, methods of contraceptives will be grouped into hormonal methods, Intra-Uterine Device (IUDs), natural methods and barriers methods. Barrier methods 14 University of Ghana http://ugspace.ug.edu.gh of contraceptives according to the American College of Obstetrics and Gynaecology (2014) includes diaphragm, sponge, cervical cap, condom and spermicide (The American College of Obstetricians and Gynecologists [ACOG], 2014). 2.4.2 Hormonal method Hormonal contraceptive refers to birth control methods which work on the endocrine system. They consist of combined oral contraceptives (COC), transdermal combined hormonal, transvaginal combined hormonal, intramuscular combined hormonal injectable and progestogen-only methods (ACOG, 2014). The COC which is the original method of hormonal contraceptive was first marketed in the 1960s as a contraceptive (Ricci & Kyle, 2014). After the development of the COC, many other delivery methods have been developed, although the oral and injectable methods are by far the most popular. Altogether, 18% of the world's contraceptive users rely on hormonal methods (Jones, 2011). There are two main types of hormonal contraceptives; the combined methods which contain both an estrogen and a progestin, and progestogen-only methods which contain only progesterone or one of its synthetic analogues (progestins). They thicken the endometrial lining making it difficult for the sperm to get to the ovum to get implanted (ACOG, 2014). It is recommended for these tablets to be taken at the same time each day. The combined methods work by suppressing ovulation and thickening cervical mucus while progestogen-only methods reduce the frequency of ovulation, most of them rely heavily on changes in cervical mucus. They include progestogen-only pill, injectable and sub-dermal implants. Combinations of estrogen and progestin prevent pregnancy by impeding the release of the hormones luteinizing hormone (LH) and follicle 15 University of Ghana http://ugspace.ug.edu.gh stimulating hormone (FSH) from the pituitary gland in the brain. LH and FSH play an essential role in the development of the egg and preparation of the lining of the uterus for implantation of the embryo (Trussell et al., 2014). Progestin also makes the uterine mucus that surrounds the egg more difficult for sperm to penetrate and, therefore, for fertilization to take place. In some women, progestin inhibits ovulation (release of the egg). The advantage of this method is that it is highly effective when properly used, as users of the steroid hormone methods experience pregnancy rates of less than 1% per year. Perfect-use pregnancy rates for most hormonal contraceptives are usually around the 0.3% rate or less per year (National Prescribing Service, 2007). However, it has its disadvantages too, which is that the woman must remember to take her pill at the same time, every day. Nausea and/or spotting are the two problems women may have during the first month of taking the pills, and the pills tend to make menstrual periods very short and light (Advocacy for Youth, 2012) 2.4.3 Intra-Uterine Device (IUD) An intra-uterine device (IUD or coil) is a small contraceptive device which is often 'T'- shaped, containing either copper or levonorgestrel, which is inserted into the uterus (Sivin & Batár, 2010). Intra-uterine methods include the copperbearing intra-uterine device (Cu-IUD), framed and unframed devices and the levonorgestrel-releasing intra- uterine system (LNG-IUS) (Sivin & Batár, 2010). The intra-uterine device (IUD) is inserted into a woman’s uterus by a health care provider. IUDs are usually made of plastic or metal that has a string attached. Their existence disrupts the physical environment of the reproductive tract. The changes can prevent fertilization of the egg and/or prevent implantation of the egg in the uterus. IUDs which contain the female hormone progesterone can stay in place up to 5 years. 16 University of Ghana http://ugspace.ug.edu.gh IUDs containing copper can stay in the uterus for up to 10 years (Advocacy for Youth, 2012). Advantages of IUDs are that they decrease menstrual cramps and the quantity of menstrual bleeding. They are also safe up until five years when they are inserted. Its disadvantages however is that it does not protect the woman against sexually transmitted diseases (Advocacy for Youth, 2012). 2.4.4 Natural/Traditional methods Natural methods of contraception refer to the traditional way of birth control. They require that a man and a woman should not engage in sexual intercourse when there is an egg ready for fertilization by a sperm (Trussell et al., 2014). Methods of natural family planning include; calendar method, temperature method, ‘coitus interuptus’, and Billing’s ovulation method. The use of natural methods of contraception is based on the realization that a woman is fertile a few days to her ovulation and few days after her ovulation has occurred. A woman is likely to get pregnant if she engages in sexual intercourse a week to her ovulation, since sperms can last in the fallopian tube for a period of 5-7 days. This method therefore requires the woman to know her menstrual cycle to be able to tell her safe and unsafe periods before she engages in sexual intercourse (Family Planning Queensland, 2005). Advantages of natural methods of contraceptives are the fact that it is cost effective, it does not interfere with the menstrual cycle of the woman and the woman gains a high level of knowledge of her body. It is however difficult when predicting ovulation of the woman, as this requires daily awareness of changes, and continued observations requires varying periods of abstinence if it is the only method used (Bullough, 2001). 17 University of Ghana http://ugspace.ug.edu.gh 2.5 Barriers to contraceptive use The use of contraceptives is based on need/desire and then access to it: stimulating this need and ensuring the availability of the methods are the major challenges faced in promoting contraceptive use (Champion & Skinner, 2008). These challenges constitute barriers, and according to Shelton and his colleagues (1992) these barriers are “practices, derived at least partly from a medical rationale, that result in a scientifically unjustifiable impediment to, or denial of, contraception” (Shelton, Angle, & Jacobstein, 1992). For a fairer understanding, some of these barriers are reviewed below. Misconceptions form a powerful barrier to the uptake of contraceptives, and such misconceptions are based, usually, on a fear of side effects (Alaii, Nanda, & Njeru, 2012). Misinformation on side effects are sometimes reported about contraceptive methods, and this can serve as a barrier to adoption or a reason for discontinuing a method (Campbell, Sahin-Hodoglugil, & Potts, 2006). Fear of side effects of contraceptives is wide spread across the globe (Asturias de Barrios, Mejia de Rodas, Nieves, Matute, & Yinger, 1998; Bongaarts & Bruce, 1995; Casterline, Sathar, & Al- Haque, 2001; El-Zanaty, Way, Kishor, & Casterline, 1999.; Yinger, 1998). In Ghana, a major reason documented by the GDHS, 2008 for non-use of contraceptives is the fear of side effect (GSS, 2009). A study conducted by Nalwadda, Mirembe, Byamugisha, Faxeli (2010) in Uganda revealed that young people believed the use of contraceptives interfered with fertility, and they were therefore frightened to use something that could endanger their ability to reproduce. Most of the married women also believed that the intake of pills placed a burden on the eggs of the woman. Both males and females also had the view that condom use can destroy the uterus, to get stuck in the reproductive tract and lead to 18 University of Ghana http://ugspace.ug.edu.gh death, not to fit properly, to be porous, and to have infectious lubricant (Nalwadda, Mirembe, Byamugisha, & Faxelid, 2010). Studies in East Africa have shown that such fears of side effects are mediated by increased income and education (Brown, Ottney, & Nguyen, 2011; Ochako et al., 2015). Other studies have further elaborated the association of a woman’s education on contraceptive decision making and choice as well as having an influence on women reproductive desires and behaviours (Ali & Okud, 2013; Andalón et al., 2014; Asfaw & Gashe, 2014; Asiimwe, Ndugga, Mushomi, & Manyenye-Ntozi, 2014; Meskele & Mekonnen, 2014). There are times that women will want to use contraceptives but the methods they desire to use will not be at their disposal (Edouard, 2009). The choice of methods available plays an important role in women’s acceptability of family planning and enables them to sustain their continuation of use (Roberts & Noyes, 2009). Ensuring the proximal availability of a range of different family planning methods will mean that people can get their desired method if the need arises. Availability of contraceptives can also be influenced by the decision to use contraceptives, distance to the facility and availability of the contraceptive methods at the health facility. Access to contraceptives services, can mean geographic or financial accessibility as well as the inability of prospective clients to get into contact with service providers at facilities where they are seek services (Frost & Darroch, 2008). Access to family planning services can also be inhibited by certain prejudices of some service providers (Edouard, 2009). Many times, in the procurement of modern methods of contraceptives, a fee is charged. For many married women in their reproductive age (15-49 years) the cost of these 19 University of Ghana http://ugspace.ug.edu.gh contraceptives are unaffordable (Creanga, Gillespie, Karklins, & Tsui, 2011). In the developed world, cost is not much of a barrier, and an increase in cost might actually be followed by increased use (Campbell et al., 2006). This problem occurs mostly in developing nations like Ghana where many women of reproductive age are inhibited from using contraceptives by poverty and financial dependence on their partners (Greene & Stanback, 2012). However, some studies have shown that increased cost causes only small reductions in use in the developing world, and in many surveys, financial cost does not often place high among the reasons women do not use contraceptives (Campbell et al., 2006; Darroch & Singh, 2013). Participants in rural Bangladesh were asked whether cost influences contraceptive use, the respondent placed little emphasis on cost (Levin et al., 1999). Molyneaux (2000) as cited in Matheny (2004) found that the increase in prices of contraceptives by 100% decreased its use by only 3 to 5% (Matheny, 2004). Ciszewski and Harvey (1994) found, however, that an average price rise of 60% for condoms in the Bangladesh social marketing program caused sales to drop by 46% (Ciszewski & Harvey, 1994). A study by Bawah (1999) showed that women cannot access contraceptive use because getting money for these contraceptives could evokes conflict in their homes (Bawah, Akweongo, Simmons, & Phillips, 1999). Service providers’ can sometimes be a barrier to the use of contraceptives. They sometimes deny people access to contraception because of their own biases about the contraceptive method or its delivery system. The power of provider bias to constrain access to contraception in many countries must be underscored continuously. In Istanbul, researchers have found that service providers failed to recommend oral contraceptives as the first choice of contraception and focused instead on health 20 University of Ghana http://ugspace.ug.edu.gh conditions that restrict the use of the pill inhibiting the choice of the pill as a method of contraception (Karavus, Cali, Kalaca, & Cebeci, 2004). In Tanzania, a study conducted by Speizer, Hotchkiss, Magnani, Hubbard, and Nelson (2000) revealed that a relatively high proportions of service providers restricted contraceptive use by age, especially for oral contraceptives, which is the most widely used method among women in Tanzania. Between 79% and 81% of service providers in rural Tanzania impose age restrictions for the pill. Of all the service providers, they showed that 10-13% of them reported that there is at least a modern method they would never recommend, and 13% reported sending a client home until her next menses, an inappropriate process barrier for the provision of most hormonal methods. These restrictions severely reduce access to contraceptives for certain groups of women. For example, young adolescents who are not married and not menstruating at the time of their visit would face one or more barriers (Speizer, Hotchkiss, Magnani, Hubbard, & Nelson, 2000). In Ghana, interviews with a sampling of providers known for creating barriers to services revealed a wide variety of restrictions impeding access to family planning methods, including marriage requirements and minimum-age restrictions imposed for reasons reflecting providers’ personal attitudes (Robinson, Moshabela, Owusu-Ansah, Kapungu, & Geller, 2014). A barrier to contraceptive use can come from a woman, her partner or her religious beliefs (Sedgh & Hussain, 2014). A panel study by Bawah in the Kasena-Nankana district in the Upper East Region of Ghana affirms that spousal communication can be an essential element in contraceptive use (Bawah, 2002); this is corroborated by other studies (Link, 2011; Ogunjuyigbe, Ojofeitimi, & Liasu, 2009). Research over the past 21 University of Ghana http://ugspace.ug.edu.gh twenty years reveal that women’s perceptions that their husbands will oppose the issue of using contraceptives has been cited as a challenge to their contraceptive usage in Ethiopia (Mohammed, Woldeyohannes, Feleke, & Megabiaw, 2014), Uganda (Agyei & Migadde, 1995), Francophone West Africa (Pearson & Becker, 2014) Tanzania (Lwelamira, Mnyamagola, & Msaki, 2012) and in many other places around the world (Bongaarts & Bruce, 1995). Concerning the role of religion in determining contraceptive use, a study in Cambodia, a deeply Buddhist country, shows that religious belief has had little or no effect on the use of contraceptives (Vathiny & Hourn, 2009). A comparative study in Nigeria done on data 18 years apart also confirmed the negligible influence of religion on the use of contraceptives (Wusu, 2014). Tawiah’s (1997) study on factors affecting contraceptive use in Ghana came out with the finding that religion and culture did not affect use of contraceptives (Tawiah, 1997). The study gave a possible reason that once a woman attains higher education, her ethnicity and religious affiliation do not have a significant effect on her current contraceptive use. This was confirmed by Adanu et al., (2009) whose findings revealed that religious affiliation did not affect contraceptive use in Accra. They however, attributed a possible reason to the fact that Accra is an urban area (Adanu et al., 2009). Women were able to make decisions regarding contraceptives use without the influence of religion and culture. However, two studies in Pakistan, a Muslim country and among Muslim minorities in India and Bangladesh was able to pinpoint religion as a substantial influence on the knowledge and use of contraceptives (Farid-ul-Hasnain, Johansson, Gulzar, & Krantz, 2013; Sahu & Hutter, 2012). Doctor et al. (2009) found that switching from traditional to the Christian or Islamic faith in the Kassena-Nankana 22 University of Ghana http://ugspace.ug.edu.gh area of Upper East region in Ghana was significantly associated with increased contraceptive use and decreased fertility (Doctor, Phillips, & Sakeah, 2009). A study by Bawah et al., (1999) in Ghana also revealed that there is fear of ancestral punishment with the use of contraceptives. Some women may want to desire to use contraceptives but will not do so, because there is a belief among most of these women that their ancestors are against the use of contraceptives, and that one may die or may not get any blessing from the ancestors if she practices contraception (Bawah et al., 1999). 23 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODOLOGY Study area, study design, target population, source of data, sampling technique and sample size, methods for data collection, analysis and ethical considerations were included in this section. 3.1 Study Design This was a cross-sectional analytical study which involved the use of quantitative methods in data collection and analysis. 3.2 Study Area The research was conducted in Paga, a community in the Upper East Region. Paga is the capital of the Kasena-Nankana West district. It is a town located in Northern Ghana, lying where the nation’s main North-South road reaches the Burkina Faso border. It has a population of about 11712 with majority living in rural settlements (GSS, 2009). The male population is about 5759 and the female population is 5953. Women of reproductive age 15-49 years were about 2729 (GSS, 2009). Paga has one public health centre and two private clinics which provides services to its people. The study was conducted in two community divisions; urban and rural. The people of Paga are mainly farmers and petty traders. 24 University of Ghana http://ugspace.ug.edu.gh Figure 3. 1: Map of Kasena Nankana West District showing the study area; Paga (Source: Department of Geography and regional planning, UCC, 2013) 3.3 Variables 3.3.1 Dependent Variable The outcome variable for the study was contraceptive use among married women in Paga. This variable was binary which was either Yes or No. it determined whether the participants used contraceptives or not. 3.3.2 Independent Variables The study assessed six independent variables and how they affect contraceptive use. These included socio-demographic, perceived susceptibility, perceived severity, perceived barriers, cue to action and misconceptions about contraceptives. - Socio-demographic characteristics assessed included age, religion, educational status, occupational status. - Perceived susceptibility was assessed by participant’s susceptibility to unwanted pregnancy. 25 University of Ghana http://ugspace.ug.edu.gh - Perceived barriers to contraceptive use was measured by evaluating what participants perceived as barriers to contraceptives use. Examples included side effects, difficulty in getting preferred methods and difficulty in getting pregnancy. - Cue to action was determined by looking at the factors that were likely to affect contraceptives use which included parity and ability to cater for children. - Perceived severity was addressed by considering the importance of contraceptive use in preventing unwanted pregnancy, STIs and reducing repeated childbirth. - Misconceptions about contraceptives were also measured by assessing what participants regarded as reasons for their non-use of contraceptives. Some of the reasons assessed were infertility, male infidelity and female promiscuity. 3.4 Study population The study’s target population were married women aged 15-49 years. The population of married women in Paga is 2729 (GSS, 2009) from which a sample size of 216 was drawn. 3.4.1 Inclusion Criteria Married women aged 15-49 years living in Paga and were not pregnant who freely consented to participate in the study. 3.4.2 Exclusion Criteria a. Married women above the age of 49 or less than 15 years b. Single women in their reproductive age of 15-49 years c. Pregnant married women aged 15-49 years d. Married women who did not give their consent to participate in the study 26 University of Ghana http://ugspace.ug.edu.gh 3.5 Sampling This section includes a description of the sample size and sampling technique used in the study. 3.5.1 Sample size estimation Sample size was estimated based on an expected CPR of 15% (this was assumed from the 2008 Ghana demographic health survey report which puts the CPR of the Upper East, where Paga is located, at 15%). However, the preliminary report of the 2014 Ghana Demographic and Health Survey puts the current contraceptive prevalence of Upper East Region at 23% (GSS, 2015). The sample size calculation was however not based on this current prevalence because as at the time the proposal was drafted, only the 2008 data that was available. A confidence interval of 95% and a significance level of 5% were used. The Cochran’s (1977) formula below was used to calculate the sample size (Cochran, 1977). 𝑧2𝑝𝑞 𝑛 = 𝑑2 Where n= sample size p = probability of the event occurring, in Upper east region, the prevalence of contraceptives is 15% (0.15) q = 1-p = probability of the event not occurring, in this case 1-0.15= 0.85 d = margin of error (0.05) Z = 1.96 normal deviate representing a 95% confidence interval 27 University of Ghana http://ugspace.ug.edu.gh The sample size was estimated as follows 1.962 ∗ (0.15)(1 − 0.15) 𝑛 = 0.052 0.489804 𝑛 = = 195.9216 0.0025 𝑛 ≈ 196 Hence, a sample size of 196 was obtained for this study. Adjusting for an anticipated 10% non-response rate, a total of 216 participants were used. The sample frame consisted of married women between ages 15-49 years who lived in Paga. 3.5.2 Sampling Technique For samples to be collected, the study site was divided into two groups, namely urban and rural. The urban constituted of Paga Central, while the rural included the surrounding communities of Paga. There were 216 participants recruited from households in both groups (108 households from each group) with one participant from each household. A sample interval of twelve was used which was obtained by dividing the target population with the desired sample size (i.e. 2729/216=12.633). A number was randomly selected from a ballot of numbers from 1 to 12, this was used to select the first household. Subsequent selection of every 12th household was then made. On arrival at each household, women of reproductive age who met the inclusion criteria were identified. Where there was no such married woman in a household, an eligible participant from the next household was selected and interviewed. In addition, where 28 University of Ghana http://ugspace.ug.edu.gh it was a polygamous home, only one of the married women that met the inclusion criteria was interviewed (based on availability and readiness). In all, 230 questionnaires were filled, but only 216 of them were validated and used for the analysis. With the help of the two research assistance, a 100% response rate was attained. 3.6 Data collection This section describes data collection tools/techniques and pre-testing 3.6.1 Data collection/techniques The study used a structured questionnaire in collecting data among married women aged 15-49 years. Participants who could read and understand were required to complete the questionnaire since all instructions and explanations were done in English language. The questionnaire contained mostly closed- ended questions. The few open - ended questions were to help the participants to provide additional information which was not included in the questionnaire and the closed-ended questions required the participants to provide answers from the options that were provided. More so, for respondents could not read and write, the questionnaire was administered by the research assistants for responses to be taken. 3.6.2 Pre-testing A pilot study was conducted in Navrongo, a neighbouring town of Paga whose married women aged 15-49 years have similar socio-demographic characteristics as that of the study area. However, these people were not included in the study. Questionnaires were pre-tested to help the researcher modify questions which did not answer the research questions and for easy administration of the questionnaire in the study area. Based on the pre-testing of the questionnaire, sections of it were revised to include questions on 29 University of Ghana http://ugspace.ug.edu.gh religion as detailed in Appendix 2. 3.7 Data analysis 3.7.1 Data processing and cleaning Questionnaires were given unique identification (ID) numbers. A data entry template was then created, and pre-coded questionnaires were manually entered into Microsoft Excel 2013 spreadsheet. Data was then imported into STATA version 13.0 for analysis. 3.7.2 Data analysis process Data analysis was done by first categorising certain variables as required, including age and education. Age was categorized into four categories of ‘15-24 years’, ’25-34 years’ ‘35-44 years’ and ’45 years and above’. SHS was merged with vocational school into one category for the educational status. All variables (including dependent and independent variables) were then described using frequencies and percentages in Table 4.1, 4.2, 4.3, 4.4, 4.5 and Table 4.6. The mean age with its standard deviation (SD) was stated in text of the results section of 4.1 in Chapter Four. A bar chart, shown as Figure 4.1, was used to illustrate comparative knowledge and use of contraceptive methods. Chi-square analysis was used to measure the associations between the socio- demographics variables and both knowledge and current use of contraceptives. These analysis are presented in Table 4.7. Furthermore, simple and multiple regressions were done to determine the strength of the association between the socio demographic characteristics of participants, and the main outcome variable (contraceptives use). This procedure assumes that there is no ordering in the categorical dependent variable. Crude and adjusted odd ratios (ORs) were calculated with a 95% Confidence Interval (95% CI). The regressions performed are shown in Table 4.8. 30 University of Ghana http://ugspace.ug.edu.gh The final analysis done was to cross-tabulate (chi square) socio-demographic variables against the four major barriers cited by study participants as reasons for not using or discontinuing the use of contraceptives. All reported p-values from all analysis (chi square and regressions) were two-tailed, and associations with p-value <0.05 were considered statistical significant. These statistically significant associations were identified on the tables with the asterisk (*) symbol. Data was analysed using STATA version 13. 3.8 Ethical considerations Before data collection, ethical approval was sought from the Ghana Health Service Ethical Review Committee of the Research and Development Division of the Ghana Health Services. Permission and approval was also sought from the Paga community (the head chief and community leaders). Also, before interviewing the participants during data collection, informed consent was obtained. The research assistants explained the study rights of the participants to them. These included rights to privacy, confidentiality and anonymity. In addition, participants were assured that their participation in the study was completely voluntary and their refusal to take part would not warrant any penalty. To ensure privacy and confidentiality, all interviews were conducted in a secluded place to ensure. Data was reported in a way that reduced the possibility of tracing the information gathered back to participants. This was done to ensure the confidentiality and anonymity of participants. Participants were given no compensation during the data collection. Their inputs were however recognized and appreciated verbally at the time of data collection. 31 University of Ghana http://ugspace.ug.edu.gh More so, the potential benefits and risk of the study were spelt out before the collection of data. The target population would be able to gain appreciable knowledge about contraceptives. Also identification of barriers to contraceptives would be used as a platform to address contraceptive needs of married women aged 15-49 years in Paga. In addition, study results would help inform decisions about prevalence and barriers to contraceptives. The research posed no risks to the target population or society. 3.9 Quality assurance The researcher employed two research assistants and one field supervisor who helped in the data collection process. To ensure reliability of data, the research assistants and the field supervisor were trained for two days on ethical considerations, procedures and meanings of the questions included in the questionnaire and how data should be collected. The researcher closely supervised the work as the research assistants carried it out. Data was checked daily for completeness, accuracy and correctness by the researcher, and problems detected by running simple frequencies and were immediately fixed. Entry of raw data was done using Microsoft Excel 2013 spreadsheet by the principal researcher to ensure accuracy and consistency of data. 3.10 Data storage and usage Questionnaires were coded and locked in a wooden-box, while the key was kept by the researcher. For the duration of data collection, data collected daily was immediately coded at the end of the day and entered within 24 hours of collection into a Microsoft Excel 2013 spreadsheet which was imported into STATA version 13.0 at the completion of data collection. Data entered was then saved under a password which was known only to the researcher. A digital copy of the dataset was stored on an external hard drive. All data collected is being kept by the researcher for 3-5 years to 32 University of Ghana http://ugspace.ug.edu.gh allow for publication of research, after which questionnaires would be properly destroyed. 3.11 Conflict of interest Apart from the academic and public health importance of the study, the researcher has no other personal interest in the study. 3.12 Dissemination of findings The study targeted the groups listed below for the dissemination of the study findings: 1. School of Public Health, University of Ghana, Legon 2. Participants involved in the survey 3. A scientific paper will be written for publication in a reputable journal 33 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS This chapter presents results of the analyses conducted in achieving the objectives of the study. It is organized as follows: ‘Background characteristics of participants’, ‘Knowledge, use and sources of information on contraceptives’, ‘Determinants of contraceptive use among participants, ‘barriers to the use of contraceptives, ‘Misconceptions about contraceptives, and ‘Perceived susceptibility and severity to contraceptive use’. 4.1 Background Characteristics of Participants This section describes the background characteristics of the participants. A total of 216 married women who were not pregnant were interviewed for the study, regardless of previous contraceptive use. The mean age of the participants in this study was 29.55 years (SD ±8.7) with an age range of 15 years to 49 years. Table 4.1 shows that the largest proportion of the participants were of the age category 25-34 years 84 (38.89%). This was followed by those in age group 15-24 years 71 (32.87%) while those aged 45 years and above constituted the smallest age group at 25 (10.65%). This age distribution implies that the participants in the study are young. Most of the participants were educated, with Table 4.1 indicating that 45 (20.83%) of the participants had completed junior secondary/middle school, a figure which is similar to the proportion of participants who completed primary school 45 (20.83%). Also, 32 (14.81%) of the participants had completed secondary school while 18 (8.33%) had tertiary level of education; however, about a third of all participants 73 (33.80%) 34 University of Ghana http://ugspace.ug.edu.gh had no formal education. A small fraction of the responses on educational attainment 3 (1.39%) were reported as missing values. In terms of religious status, majority of the participants were Christians 145 (67.13%), with Muslims being the second biggest religious grouping at 58 (26.85%), and 13 (6.02%) of participants stated that they were practitioners of traditional religion. In addition, most of the participants were employed 152 (70.37%). In terms of residential status of the participants, 126 participants (58.33%) were rural dwellers, while 90 (41.67%) of the study participants were urban dwellers. 35 University of Ghana http://ugspace.ug.edu.gh Table 4. 1 : Socio-demographic characteristics of Participants Variable name Frequency Percentage (n=216) (%) Age (years) 15-24 71 32.87 25-34 84 38.89 35-44 38 17.59 45 and above 23 10.65 Educational Status No formal education 73 33.80 Primary 45 20.83 JHS/Middle School 45 20.83 SHS/Vocational School 32 14.81 Tertiary 18 8.33 Missing 3 1.39 Religion Christian 145 67.13 Muslim 58 26.85 Traditional religion 13 6.02 Occupational Status Unemployed 64 29.63 Employed 152 70.37 Residence Rural 126 58.33 Urban 90 41.67 JHS: Junior High School SHS: Senior High School 4.2 Knowledge, Use and Sources of Contraceptives Table 4.2 depicts participant’s knowledge, use and their sources of information on contraceptives. From Table 4.2, 175 (81.02%) participants reported having ever heard of contraceptives. In addition, 122 (56.48%) participants representing more than half of the participants, indicated they had ever used any method of contraceptive. Again, regarding the sources of contraceptives, 50 (40.8%) of the participants who had eve used reported that they obtained the contraceptive used from a government health 36 University of Ghana http://ugspace.ug.edu.gh centre. CHPS centres served as a source of contraceptive for 36 (29.51%) participants, government hospitals did same for 21 (17.21%) participants and pharmacies for 10 (8.20%) participants. Private clinics and peer educators both represented contraceptive source for just 2 (1.64%) and 1 (0.82%) of the participants respectively. Among all the participants, 41 (18.98%) of them reported current use of contraceptives. Hence, the prevalence of contraceptive among the participants in Paga was 18.98%. Among, the 41 participants who reported current use, 40 (18.52%) of them reported using modern methods while only 1 person (0.46%) was a traditional method user. 37 University of Ghana http://ugspace.ug.edu.gh Table 4. 2: Knowledge, use and sources of information on contraceptives (n=216) Variable Frequency Percent Knowledge of contraceptives Ever heard of contraceptives 175 81.02 Have not heard of contraceptives 41 18.98 Total 216 100.00 Ever use of contraceptives Have used contraceptives 122 56.48 Have not used contraceptives 94 43.52 Total 216 100.00 Source of contraceptive used (n=122) Government hospital 21 17.21 Government health centre 50 40.98 CHPS* 36 29.51 Field worker/Peer educator 1 0.82 Private clinic 2 1.64 Pharmacy 10 8.20 Other 2 1.64 Total 122 100.00 Current use of contraceptives Use contraceptives 41 18.98 Does not use contraceptives 175 81.02 Total 216 100.00 Current contraceptive use by method-type Current use of modern contraceptives 40 18.52 Current use of traditional methods 1 0.46 Not using any method currently 175 81.02 Total 216 100.00 *CHPS= Community based health programme and services 4.3 Knowledge and use of contraceptives among Participants Figure 4.2 shows an overview of the knowledge and use of contraceptives among the participants. The participants in this study mostly knew of pill method of contraceptive (78.29%) but this did not translate to a similar high use, as pills were currently used by 4.63% of the participants as compared to depo/injectables with usage by 9.26% of the participants. Tubal ligation, jadelle and male condom were the least used though they were aware of it. Vasectomy, intra-utrine device (IUD), female 38 University of Ghana http://ugspace.ug.edu.gh condom, diaphragm, foam/jelly, emergency contraceptive and Lactational Amenorrhia (LAM) recorded no usage. Ever-heard Current use 90 80 70 60 50 40 30 20 10 0 Figure 4. 1: Knowledge and use of contraceptives among participants (modern methods). 4.4 Factors that are likely to affect contraceptives use Table 4.3 indicates the factors that are likely to affect contraceptives use among the 216 participants that were interviewed. Parity was considered because women who have reached their desired family size are those likely to use contraceptives. From Table 4.3, 147 participants representing 68.06% had 1-4 children while those without children represented the smallest proportion among the participants 30 (13.89%), women in this parity would be more likely to use contraceptives. A woman’s ability or inability to cater for her children can also influence her decision to use contraceptives. Among women who had ever given birth, 161 (86.56%) said they were able to take of care of their children whereas 25 (13.44%) reported inability to cater for their children. 39 14.29 2.31 10.86 0 78.29 4.63 12 0 76 9.26 30.29 2.78 56 2.31 17.71 0 8 0 17.71 0 8.57 0.46 7.43 0 University of Ghana http://ugspace.ug.edu.gh Participants stated the reasons for the use of contraceptives as well as their choice of contraceptive methods. Among ever users of contraceptives, Table 4.3 shows that birth spacing was the major reason for using contraceptives 105 (86.07%) followed by using it to limit or stop birth 25 (20.49%). Treatment of infertility 5 (4.1%) and menstual inregularities 2 (1.64%) were the reasons least cited by the participants. Source of information on contraceptives can also influence a woman’s decision to use contraceptives. For instance, in Table 4.3, majority of the participants (95 participants constituting 77.87% of ever-users) indicated they heard of contraceptives from health workers followed by 42 (34.43%) participants who heard it from friends. Some also reported hearing of contraceptives through advertisements on TV’s and radio 15 (12.3%). Also, participants were asked if they discussed with their partners before using contraceptives. This is because partner discussion can influence a woman’s decision to either use contraceptives or not use contraceptives. From Table 4.3, 108 women (88.52%) reported they had discussed with partners before use whilst only 14 (11.48%) reported they did not discuss with their partners before use. 40 University of Ghana http://ugspace.ug.edu.gh Table 4. 3: Factors that are likely to affect contraceptive use among Participants (n=216) Variable Frequency Percent Parity None 30 13.89 1-4 Children 147 68.06 5-8 children 39 18.06 Ability to Care for children among all Participants Have Ability 161 86.56 Does not have ability 25 13.44 Reason for using contraceptives Birth space 105 86.07 Limit or stop children 25 20.49 Treat infertility 5 4.1 Treat menstrual irregularity 2 1.64 Other 2 1.64 Source of information (n = 122)a Friend's use 42 34.43 Advise from health worker 95 77.87 Advertisement (radio, TV etc) 15 12.3 Other 1 0.82 Spousal communication (n=122) Discussed with partner 108 88.52 Did not discuss 14 11.48 aOther sources of information included family members and information from school 41 University of Ghana http://ugspace.ug.edu.gh 4.5 Barriers to contraceptives use Table 4.4 illustrates what participants perceived as barriers to their never use as well as their reasons for discontinuing the use of contraceptives. Among all participants, 122 (56.48%) had ever used contraceptives whilst 94 (43.51%) had never used contraceptives. Of the 94 who had never used contraceptives, most of them indicated the fear of side-effects 32 (34.04%) as their reason for non-use of contraceptives, with other major barriers being the infertility/difficulty in getting pregnant 20 (21.28%), difficulty in obtaining the preferred method of contraceptives 19 (20.21%) and religious beliefs 16 (17.02%). The cost of contraceptives 4 (4.25%) and family opposition 4 (4.25%) to use were the least reported barriers by the participants. Of the participants who had ever used contraceptives, 81 (66.3%) discontinued use while 41 (18.98%) were current users. Of the 81 participants who discontinued used, 34 (41.98%) indicated they stopped its use to have more children while 21 (25.93%) stated side effects as the main reason for discontinuity of method used. Other key reasons they stated were opposition from partners 10 (12.35%) and the difficulty in getting preferred methods 8 (9.88%). Only two participants 2 (2.47%) named the cultural-borne fear of ancestral punishment as a reason for stopping the use of contraceptive. 42 University of Ghana http://ugspace.ug.edu.gh Table 4. 4: Barriers to the use of contraceptives Variable Frequencya Percent Barriers to ever use of contraceptives (N=94) Religious belief 16 17.02 Distance to acquisition 15 15.95 Partner opposition 13 13.83 Family opposition 4 4.25 Side effects 32 34.04 Infertility/difficulty in getting pregnant 20 21.28 Hard to get preferred methods 19 20.21 Cost of contraceptives 4 4.25 Want more children 15 15.95 Attitude of service providers 11 11.70 Other 12 12.77 Reasons for discontinuity (N=81) Religious belief 5 6.17 Distance to acquisition 7 8.64 Partner opposition 10 12.35 Family opposition 7 8.64 Side effects 21 25.93 Hard to get preferred methods 8 9.88 Cost of contraceptives 5 6.17 Want more children 34 41.98 Attitude of service providers 5 6.17 Fear of ancestral punishment 2 2.47 Menopause 7 8.64 Other* 5 6.17 *Other reasons for discontinuity of use of contraceptives was personal loss of interest a frequencies include only participants who indicated Yes to the barriers of contraceptives 43 University of Ghana http://ugspace.ug.edu.gh 4.6 Misconceptions about contraceptives Considering the role misconceptions can play in preventing women from using contraceptives, it is pertinent to observe from Table 4.5, that the perception of contraceptives causing infertility was the most prevalent with 123 participants (57.48%) agreeing with that viewpoint. The use of contraceptives encouraging male infidelity and causing cancer were also major misconceptions voiced by 101 (47.20%) and 98 (45.58%) of all participants respectively. Marking the least reported misconception, 68 (31.63%) of all participants believed that contraceptives are meant only for married people. This finding shows that the stated misconceptions in Table 4.5, apart from beliefs on infertility, were not shared by majority of the participants and the result also ties well with the fact that the major barrier to contraceptive use among participants is the fear of side-effects. Table 4. 5: Barriers to the use of contraceptives (n=216) Variable Yes No Don't Total n (%) n (%) Know N n (%) Causes infertility 123 (57.48) 55 (25.70) 36 (16.82) 214 Encourage female promiscuity 89 (41.40) 84 (39.07) 42 (19.53) 215 Encourage male infidelity 101 (47.20) 61 (28.50) 52 (24.30) 214 Causes cancer and other diseases 98 (45.58) 70 (32.56) 47 (21.86) 215 Meant for only married people 68 (31.63) 117 (54.42) 30 (13.95) 215 *Total includes 5 cases with missing information on misconceptions about contraceptives 44 University of Ghana http://ugspace.ug.edu.gh 4.7 Perceived susceptibility and severity to contraceptive use Participants were also asked how serious they think the consequences of not using contraceptives would be and whether they can become pregnant without the use of contraceptives. These were measured using perceived severity and susceptibility. From table 4.6, majority of the participants said that they were susceptible to unwanted pregnancy 120 (55.81%), repeated child birth affecting the health of the woman or mother 73 (34.11%), and repeated child birth draining income of the family 50 (23.47%). In addition, participants also reported susceptibility to STIs 47 (21.86%) and abortion 13 (14.49%). Susceptibilities other than those prescribed in the questionnaire were cited by 2 participants (0.93). Perceived severity was first assessed by asking participants if they felt there was a need for contraceptive use. This was to determine how serious participants perceived the outcome of not using contraceptives would be. Of the 170 participants (78.7%), who indicated the need for contraceptives, majority of them 155 (91.18%) expressed the opinion that contraceptives were needed to prevent unwanted pregnancy, 99 (58.24%) of them indicated that contraceptives were needed to reduce repeated child-birth and 67 (39.41%) saw the necessity of contraceptives in improving the health of the mother. The two rationales for using contraceptives least reported were to obtain economic benefits 28 (16.47%) and other reasons 1 (0.59%). 45 University of Ghana http://ugspace.ug.edu.gh Table 4. 6: Perceived susceptibility and severity to contraceptive use (n=216) Variable Yes No Total Freq. % Freq. % Freq. Perceived susceptibilitya Unwanted pregnancy 120 55.81 95 44.19 215 STIs 47 21.86 168 78.14 215 Repeated child birth affects 73 34.11 141 65.89 214 mother’s health Repeated child birth drains 50 23.47 163 76.53 213 income Repeated child birth affects 33 15.42 181 84.58 214 health of children Abortion 31 14.49 183 81.51 214 Other 2 0.93 212 99.07 214 Perceived severity Need for contraceptives 170 78.7 46 21.3 216 Need to prevent unwantedb 155 91.18 15 8.82 170 pregnancy Prevent STIsb 42 24.71 128 75.29 170 Reduce repeated child birthb 99 58.24 71 41.76 170 Improve the health of the 67 39.41 103 60.59 170 motherb Obtain economic benefitsb 28 16.47 142 83.53 170 Otherb 1 0.59 169 99.41 170 aTotal includes 7 cases with missing information on perceived susceptibility to contraceptive use. b Perceived severity was based on number of participants who said contraceptives had importance (n=170) 46 University of Ghana http://ugspace.ug.edu.gh 4.8 Associations between Participants’ characteristics with current use and knowledge of contraceptives From Table 4.7, a chi-square analysis was done to determine the associations between respondent’s socio-demographic characteristics with their knowledge and use of contraceptives. Contraceptive knowledge was observed to be highest among age group 25-34 years 75 (89.29%), while participants aged 45 and above had the least knowledge of contraceptives 15 (65.22%). The level of contraceptive knowledge among the youngest age group 15-24 years 55 (77.46%) and those aged 35-44 years 30 (78.95%) was similar, with this age-based difference in knowledge being significant at p<0.05. An almost identical pattern is seen in terms of contraceptive use and age, as contraceptive prevalence is highest among participants aged 25-34 years 24 (28.57%), lowest among those aged 45 years and above (4.35%) and similar among the age groups 15-24years 11 (15.49%) and 35-44 years 5 (13.16%). This is because those in age 35-44 years and 45 years and above have reached their desired number of children and are probably experiencing menopause. More so, those in age group 15-24 years are now beginning childbearing and hence the low use of contraceptives among these age categories. This association however also showed statistical significance (p<0.05). The association between the educational status of a married woman and both her knowledge and use of contraceptives was also found to be statistically significant (p<0.05) respectively. Participants who had tertiary education had the most knowledge of contraceptives 17 (94.44%), but their use was lower 5 (27.78%). Women with secondary school education were the highest users 12 (37.50%) and second most knowledgeable of contraceptives 29 (90.63%). Those with no formal education had both the lowest level of knowledge 51 (69.86%) and use 5 (6.85%) while one in five 47 University of Ghana http://ugspace.ug.edu.gh women with primary education currently use 9 (20.00%) even though a higher proportion of them knew of at least one contraceptive method 39 (86.67%). In addition, there was a significant association between participants’ residential status and their knowledge and use of contraceptives with p<0.05. The study however found no significant associations between participants’ knowledge and use of contraceptives with their religion, occupational status and parity (p>0.05). Similarly, the associations between spousal communication and current use of contraceptives was not also significant at p>0.05. 48 University of Ghana http://ugspace.ug.edu.gh Table 4. 7: Associations between Participants’ characteristics with current use and knowledge of contraceptives Variable Current use of contraceptives Knowledge of contraceptives N= 216 Yes, n (%) ᵪ2 (p-value) Yes, n (%) ᵪ 2 (p-value) Age (years) 15-24 11 (15.49) 55 (77.46) 25-34 24 (28.57) 75 (89.29) 9.626 (0.022)* 8.156 (0.043) * 35-44 5 (13.16) 30 (78.95) 45 and above 1 (4.35) 15 (65.22) Educational status No formal education 5 (6.85) 51 (69.86) Primary 9 (20.00) 39 (86.67) JHS/Middle school 10 (22.22) 15.193 (0.004)* 37 (82.22) 10.998 (0.027)* SHS/Vocational 12 (37.50) 29 (90.63) Tertiary 5 (27.78) 17 (94.44) Religion Christian 28 (19.31) 118 (81.38) Muslim 13 (22.41) 3.500 (0.174) 49 (84.48) 3.673 (0.159) Traditional religion 0 (0.00) 8 (61.54) Occupational status Employed 32 (21.05) 127 (83.55) 1.431 (0.232) 2.122 (0.143) Unemployed 9 (14.06) 48 (75.00) Parity None 5 (16.67) 26 (86.67) 1-4 Children 30 (20.41) 0.627 (0.731) 121 (82.31) 2.940 (0.230) 5-8 children 6 (15.38) 28 (71.79) Residence Rural 16 (12.70) 92 (73.02) 7.763 (0.005)* 12.593 (<0.001)* Urban 25 (27.78) 83 (92.22) Spousal communication (N=120)* Discussed with partner 38 (35.19) N/A 0.797 (0.372) Did not discuss 3 (21.43) *N/A= Not Applicable *Two missing cases *significant at 0.05 49 University of Ghana http://ugspace.ug.edu.gh 4.9 Results of regression analysis In determining the relationship between participants’ background characteristics and their contraceptive use, both simple and multiple logistic regression analyses were done. From Table 4.8, age group 25-34 years had higher odds of using contraceptives relative to age group 15-24 years, this relationship was not significant (OR=2.182, 95% CI=0.982-4.848; p>0.05). However, when education, religion, occupational status, and parity were controlled for, the association became statistically significant (AOR=4.078, 95% CI=1.314-12.656; p<0.05). The other age groups showed no significant relationship with contraceptive use even after adjusting for the other selected characteristics. Table 4.8 further illustrates that education is an important predictor of contraceptive use as participants who completed primary education had 3.4 times significantly greater odds of using contraceptives as compared to the odds of having no formal education (95% CI=1.060-10.905; p<0.05), but when all other characteristics are held constant, the relationship becomes insignificant with contraceptives use (p>0.05). In contrast, married women with a secondary school education consistently showed significantly higher odds of using contraceptives than those who never got formal education both at crude analysis (JHS/middle school: OR=3.886, 95% CI= 1.232-12.251; p<0.05. SHS/vocational OR=8.16, 95% CI= 2.567-25.933; p<0.05) and when other factors are adjusted for (JHS/middle school: AOR=5.767, 95% CI=1.472-22.591; p<0.05. SHS/vocational AOR=22.062, 95% CI= 4.425-10.990; p<0.05). Place of residence was also a significant predictor of contraceptive use, as urban dwellers had 2.6 times significantly greater odds of using contraceptives than rural dwellers (95% CI= 1.315-5.316; p<0.05), and when other variables are held constant, they had 2.7 greater odds of using contraceptives relative to rural dwellers (95% CI= 50 University of Ghana http://ugspace.ug.edu.gh 1.219-6.074; p<0.05). The other characteristics, which included occupational status, religion and parity, did not show any significant relationship with contraceptive use (p>0.05). The logistic regression only explains about 18% of variability in the outcome variable. 51 University of Ghana http://ugspace.ug.edu.gh Table 4. 8: Results of regression analysis Characteristic Odds ratio (95% p- Adj. Odds ratio (95% p- C.I) value C.I)a value Age (years) 15-24 Ref. - Ref. - 25-34 2.182 (0.982-4.848) 0.051 4.078 (1.314-12.656) 0.015* 35-44 0.826 (0.265-2.582) 0.743 2.678 (0.519-13.819) 0.239 45 and above 0.248 (0.302-2.034) 0.194 0.801 (0.067-9.556) 0.861 Educational status b No formal Ref. Ref. - education Primary 3.400 (1.060- 0.040* 3.345 (0.931-12.015) 0.064 10.905) JHS/Middle 3.886 (1.232- 0.021* 5.767 (1.472-22.591) 0.012* school 12.251) SHS/Vocational 8.16 (2.567-25.933) <0.05* 22.062 (4.425-10.990) <0.001 * Tertiary 5.231 (1.323- 0.018* 4.331 (0.881-21.299) 0.071 20.673) Religion Christian Ref. Ref. Muslim 1.207 (0.575-2.436) 0.619 0.922 (0.392-2.171) 0.852 Traditional religion c Occupational status Employed 1.629 (0.728-3.646) 0.235 2.405 (0.823-7.030) 0.109 Unemployed Ref. Ref. - Parity None Ref. Ref. - 1-4 Children 1.282 (0.453-3.629) 0.640 1.531 (0.415-5.650) 0.523 5-8 children 0.909 (0.249-3.321) 0.885 3.452 (0.551-21.644) 0.186 Residence Rural Ref Urban 2.644 (1.315-5.316) 0.006* 2.721 (1.219-6.074) 0.015* Ref. - Reference category; a Multiple regression statistics: Number of observations= 200; Goodness-of- fit measures- McFadden’s unadjusted pseudo R2=0.1803, Cox-Snell’s pseudo R2=0.167; Nagelkerke’s pseudo R2=0.262 Likelihood ratio (LR) chi-square p-value=0.003. b Educational status variable had 3 missing values. c Excluded because all 13 Participants who practiced this religion did not use contraceptives; as such, this category perfectly predicts failure to use contraceptives. *P-values are significant at <0.05 52 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSION 5.1 Introduction The study sought to investigate the barriers to contraceptive use among married women in Paga using the health belief model, and guided by the constructs of perceived threats (susceptibility and severity), perceived barriers, cue to action, and misconceptions about contraceptives. The study population comprised solely of married women, with more than two-thirds of the participants being below the ages of 34 years. This mirrors the population structure of Ghana and the pattern of age distribution in some fertility studies conducted in the Upper East region (Achana et al., 2015; Doctor et al., 2009; GSS, 2006). Educational attainment among the participants was low with more than half of all participants having less than a primary school education, and just below one in ten participants having a post-secondary education. Critical to the use of contraceptives is the knowledge of its existence, hence, any endeavour directed at assessing barriers to use must begin by measuring the existent knowledge (Sedgh et al., 2007). In literature, the lack or low levels of knowledge and access to information about contraceptives is widely cited as a key determinant of contraceptive use (Campbell et al., 2006; Cleland et al., 2006). As such, an objective of this study was to measure the level of knowledge of any method of contraceptives among married women in Paga. The results showed that knowledge of any method of contraceptive was very high (81.02%) among the participants, but it was much lower than the figure (96.9%) cited in the in the 2008 Ghana Demographic Health Survey for the same measure among married women in the Upper-East region (GSS, 2009). In 53 University of Ghana http://ugspace.ug.edu.gh addition, the high contraceptive knowledge observed among participants did not result in high levels of current use, with about 70% of those who knew of any contraceptive method having ever used, while current users were just above a fifth of those who had the knowledge. A study by Apanga and Adam (2015) in the Upper East region also found similarly high levels of family planning knowledge as this present study did (89%), but they reported that such high knowledge was accompanied by a low utilization of family planning services (18%) (Apanga & Adam, 2015). This trend is similar to a study by Sedgh et al., (2007) which shows that in the developing world, despite a relatively high knowledge, use remains low (Sedgh et al., 2007). This points to the existence of barriers that are hindering people from using contraceptives that would be beneficial to them (Cleland et al., 2006). The GDHS (2008) also show similar findings, as knowledge of any method is 99% for men and 98% for women while ever use of contraceptives among currently married women is 60% and current use being 24% (GSS, 2009). In this study, knowledge of a method was highest for the pill method of contraceptive, followed by depo/injectables and male condoms, this is reflective of findings in the 2008 GDHS. In addition, the prevalence of knowledge was found to be associated with age and education, with knowledge being highest in the middle aged (25-34 years old) and greater among highly-educated women (secondary and tertiary levels of education). A study by Aryeetey et al. (2010) in the Ga East district of Greater Accra among women of ages 15-49 years further corroborates the association of education and knowledge. The authors found that knowledge of any modern method of contraceptives was near universal at 99.7% of all participants, with the number of modern methods known to women increased with increasing level of education (Aryeetey et al., 2011). 54 University of Ghana http://ugspace.ug.edu.gh The contraceptive prevalence rate (CPR) found in this study (18.98%) is similar to the figure found in a review by Pacqué-Margolis, Cox, and Puckett, Schaefer (2013), which showed that sub-Saharan Africa has a CPR of 19%, a figure which considers across national prevalence rates ranging from 1% in Somalia to 60% in South Africa (Pacqué- Margolis et al., 2013). It is also comparable to the findings of the 2014 Ghana Demographic and Health Survey which showed that the contraceptive prevalence rate in the Upper East region was 23.7%, a figure representing a 9% increase from the 2008 GDHS findings (GSS, 2009, 2015). Modern methods of contraceptives were more widely used than traditional ones, with 18.52% of those using any method using modern methods. Among these modern methods, hormonal methods of contraceptives were the most commonly used, with depo/injectables observed as the most used followed by the use of pills and implants. These findings are in close agreement with those of the 2014 Ghana Demographic and Health Survey preliminary report which shows that modern methods of contraceptives are commonly used than traditional methods (GSS, 2015). Again, the findings are similar with results from a study by Khan et al., which showed that the most commonly used modern methods in the developing world are the pill and depo/injectables (Khan et al., 2007). The study found a significant relationship between age and contraceptive use. Age group 25-34 years not only had significantly higher odds of contraceptive use than age group 15-24 years. The results from this study is similar to findings from a study by Asiimwe, Ndugga and Mushomi (2013) which found consistently higher use of contraceptives among age group 25-34years relative to those aged 15-24 years (Asiimwe, Ndugga, & Mushomi, 2013). Furthermore, another study in the US among 55 University of Ghana http://ugspace.ug.edu.gh diabetic women found that those aged had 25% higher odds of using contraceptives than those aged 18-24 (Chuang, Chase, Bensyl, & Weisman, 2005). The educational status of a woman was also found to be a strong predictor of contraceptive use, with the odds of use increasing as educational level does. Those with secondary school education had the highest significant odds relative to participants with no formal education. This is likely because increasing education exposes women to more information on contraceptives, which in turn increases their likelihood of usage. This relationship between education is by both the 2014 GDHS where those with secondary and over education having higher use of contraceptives, and a study by Achana et al. (2015) where they found similar patterns of increased used and odds of use as educational level increased (Achana et al., 2015; GSS, 2015). Place of residence was found to be a consistently significant determinant of contraceptive use, as those in urban areas had more than twice the odds of contraceptive use than participants who lived in rural areas. This can be explained by the fact that urban residents not only have easier access to contraceptives but they are also less inhibited to use by socio-cultural norms that are more binding in rural areas. This is corroborated by the findings of a study in Nigeria comparing contraceptive use among rural and urban woman which found that urban women had more than twice the usage of contraceptives compared to rural women (Olalekan & Olufunmilayo, 2012). In addition, a study in Ghana by Nonvignon & Novignon (2014) consistently found statistically significant differences in contraceptive use between 1988 and 2008 among rural and urban women, with urban women having higher use than rural dwelling women (Nonvignon & Novignon, 2014). 56 University of Ghana http://ugspace.ug.edu.gh The likelihood of a married woman considering herself to be susceptible to unwanted pregnancy, maternal morbidity or mortality was investigated in this study. Where a respondent considers herself as being susceptible to unwanted pregnancy or maternal morbidity or mortality, she would opt for contraceptive use according to the assumption of the study; however, where the perception is low, the respondent would be less likely to act in preventing it (Kershaw, Niccolai, Ethier, Lewis, & Ickovics, 2003). Perceptions of susceptibility varied among participants in this study, with just more than half of all participants (55.81%) admitting they felt susceptible to unwanted pregnancy, and about 23% of the participants stating that they were susceptible to repeated child birth affecting the health of the mother; perceived susceptibility was however lower for abortion (14.49%). This was in contrast to studies reviewed by Frohwirth et al. (2013) where perceptions of susceptibility to unwanted pregnancy was low, with only those who were having frequent unprotected sexual intercourse feeling more susceptible to unwanted pregnancy (Frohwirth, Moore, & Maniaci, 2013). In this study, a woman’s belief of been at risk for unwanted pregnancy did not translate to current use, considering that only about 19% of the study participants were current users of contraceptives while just over 50% had ever used contraceptive. Rahman et al. (2012) also had similar findings, as their study showed that a clear perception of susceptibility to undesirable reproductive outcome does not equate to the use of contraceptives (Rahman, Berenson, & Herrera, 2013). However, a study conducted in Myanmar showed that there was a significant association of perceived susceptibility to getting an unplanned pregnancy with the use of contraceptives among married women (Mon & Liabsuetrakul, 2012). The gap observed in this study between views of susceptibility and use could be because of seeming barriers faced by participants’, such 57 University of Ghana http://ugspace.ug.edu.gh as a fear of side effects, which was mostly cited in this study by participants as a reason for their non-use and discontinued use of contraceptives. How serious participants perceived a particular health outcome to be was explored. In this study, the assumption was that the more serious a particular health outcome is perceived to be, the more action participants would take to prevent the outcome from occurring (Carpenter, 2010). This assumption was assessed by asking participants if there is the need for contraceptives and what this need is. For example, if a married woman thinks without the use of contraceptives, she is likely to get an unwanted pregnancy which can in turn affect her health and consequently drain the family’s income, she has perceived the seriousness of not using contraceptives, which would then spur her to begin using contraceptives. The results of this study showed that the proportion of those who believed there was a need for contraceptives (78.7%) was slightly lower than those who knew of at least one method but was about four times greater than the proportion of current contraceptive users. This points to the fact that knowledge does not fully equate perceptions of severity as those who do know about contraceptive may still not see a need for it. In contrast, a study among young adults in the United States found that women's greater contraceptive knowledge was related to an increased likelihood that they saw the need for it and consequently used specific contraceptive methods (Frost et al., 2012). Most participants who saw a need for contraceptives in this study said it was needed to prevent unwanted pregnancy and for reducing repeated childbirth (child spacing), both of which are identical to the main reasons for ever use of contraceptives given by participants (which was to limit and space births). They are also similar to the most cited perceptions of susceptibility (which was to prevent unwanted pregnancy and 58 University of Ghana http://ugspace.ug.edu.gh reduce repeated childbirth). Perceptions that contraceptive are needed to obtain economic benefits (and reduce draining of the family’s income) was low at just 16.47%, showing that most participants felt financially secure enough not to see economic loss as a consequence of not using contraceptives. This explains the fact that only a slightly lower proportion of participants (13.90%) who have children reported not being able to take care of their children. A study that was conducted in the US had contrasting findings as they reported that married women’s contraceptive use is promoted by their concerns about their ability to care for their children, (Parnell & National Research Council, 1989). Barriers to contraceptives use which is the main focus of the study was discussed under reasons for never use and discontinued use. Barriers refer to a respondent’s perception of the obstacles to a desired behaviour. Even if an individual has a high perception of susceptibility to a health condition, believes the potential consequences of the condition are adverse and presumes that risk-reduction actions taken will be effective, barriers may still prevent the uptake of that health-promoting behaviour (Champion & Skinner, 2008). Its use as a key construct in this work is backed by empirical evidence from a study by Carpenter (2010) that shows that perceived barrier was consistently the strongest predictor of health behaviour: and as such it would be very relevant in using it to access contraceptive behaviour (Carpenter, 2010). In this study, a recurrent trend in the results obtained was that side-effects was the most cited barrier to use by both those who never used and those who stopped using, with difficulty in getting methods and difficulty in getting pregnant/infertility being also consistently reported as important reaons for non-use. Over all, 59.97% of the participants cited side effects as the reason for use and non-use of contraceptives (34.04% never users and 25.93% discontinued users). This finding confirms other study 59 University of Ghana http://ugspace.ug.edu.gh results like that of the GDHS (2008) which also cited the fear of side effects as one of the reasons for non-use of contraceptives (GSS, 2009). More so, a study by Campbell et al., 2006 also revealed that the fear of side effects can be a factor for the use and non- use of contraceptives (Campbell et al., 2006). Furthermore, this study confirms findings from previous works that reported the fear of side effects of contraceptives as a common barrier to contraceptive use (Asturias de Barrios et al., 1998; Bongaarts & Bruce, 1995; Casterline et al., 2001; El-Zanaty et al., 1999.; Yinger, 1998). Also, difficulty in getting pregnant was the second most important reason for non-use of contraceptives (21.28%). Considering the rural and largely low-educated setting of the study, it is not surprising that people would not want to use contraceptives because they want to preserve their fertility; this is because in this side of the world, a woman’s worth is defined by her ability to procreate (Akujobi, 2011). This finding was similar to a qualitative study in Kenya carried out among young women where some participants believed that modern contraception methods could cause temporary infertility or reduce one’s childbearing capacity, limiting the number of children they were able to conceive in their lifetime; although another study shows that such fears are mediated by increased income and education (Brown et al., 2011; Ochako et al., 2015). Fear of not being able to become pregnant pushes women away from using contraceptives because it it believed that the use of pills puts a burden on the woman’s eggs causing infertility and condom use can also destroy the uterus of the woman (Nalwadda, Mirembe, Byamugisha, & Faxelid, 2010). The choice of methods available plays an important role in women’s acceptability of family planning and enables them to sustain their continuation of use (Roberts & Noyes, 2009). Hard to get prefered method was the third most important reason cited for non- use of contraceptives (220.21%), it was however not a major reason for discontinuity 60 University of Ghana http://ugspace.ug.edu.gh of method use (9.88%). Availability of prefered methods can be influenced by several other factors such as the decision to use contraceptives and financial accessibility (Edouard, 2009). Edouard (2009) also noted that access to contraceptives and individual’s ability to get preferred methods can be influenced by service providers (Edouard, 2009). Financial access as a barrier is reiterated by Creanga et al. (2011), while a RCT study showed that removing the requirement to obtain contraceptives increases use (Creanga et al., 2011; Raine et al., 2005). Infrequent supply in terms of service provision and availability is also a barrier canvassed by Frost & Darroch (2008) which explains a dimension of why participants felt preferred method was hard to get (Frost & Darroch, 2008). As a barrier to contraceptive use, the study also noted the barrier relating to attitude of health workers. It was however not a major barrier as only 17.87% of the participants (11.70% never use and 6.17% discontinued use) pointed out attitude of service providers as a barrier. Though not a major barrier, it supports the findings of Speizer, Hotchkiss, Magnani, Hubbard, and Nelson (2000) who revealed that relatively high proportions of service providers restricted contraceptive use by age. Again, Karavus, Cali, Kalaga and Cebeci (2004) revealed that service providers inhibited contraceptives among its seekers (Karavus et al., 2004). Religious belief was yet another barrier to contraceptive use cited by the participants with about 23.19% of the participants giving this reason (17.02% for non- use and 6.17% discontinued use). This study’s findings confirmed studies done by Farid-ul- Hasnain, Johansson, Gulzar, & Krantz, 2013; Sahu & Hutter, (2012) in Pakistan which revealed that religion has a sunstential influence on knowledge and use of contraceptives. However, studies in Ghana conducted by Tawiah (1997) and Adanu et al., (2009) showed religion did not affect the use of contraceptives based on increasing educational attainment and the urban setting of the study respectively (Tawiah, 1997; 61 University of Ghana http://ugspace.ug.edu.gh Adanu et al., 2009). Further, it would be simplistic to assume that religion consistently inhibits the use of contraceptives as a study by Doctor et al. (2009) showed that switching from traditional to the Christian or Islamic faith was significantly associated with increased contraceptive use and decreased fertility (Doctor et al., 2009). Factors that motivate married women to use contraceptives includes promotion of awareness on contraceptives, reminders and any stimulus that triggers the decision to begin or continue using contraceptives (Champion & Skinner, 2008). The researcher considered spousal communication and reasons for use of contraceptives as the motivational factors that would make a married woman want to use contraceptives, as well as her source of information on contraceptives. Majority of the participants (86.07%) reported birth spacing as their reason for using contraceptives, 20.49% of the participants also indicated that they used contraceptives to limit/stop child birth. This finding is attuned to the 2008 GDHS report which states that the use of contraceptives is primarily for limiting and spacing. Spousal communication has been said by literature to be a key determinant of continued contraceptive use (Link, 2011; Ogunjuyigbe et al., 2009). However, this study did not find such an association, perhaps implying that although a greater percentage of women who discussed with their spouses still used than those who didn’t, partner discussion was not a major predictor of use. This also illuminates the fact that partner opposition as a reason for discontinuity was cited by barely above one in ten women in the study and was the seventh most cited for not ever using. Similar findings in Ethiopia shows that married women’s communication and relationship quality had no statistical effect on their uptake and continuity of contraceptives (Neetu, Assefa, Meselech, & Tsui, 2015). 62 University of Ghana http://ugspace.ug.edu.gh Women’s sources of information about contraceptives was mainly from health workers, although the use by friends was the next most important contraceptive information source. It is informative that a greater percentage of those who got their information from health workers (36.23%) only were using contraceptives than those who got from friends (31.25%), while those who got the information from the media had even higher rates of continuity (40%), although all of these associations are not significant. Considering how misconceptions can affect the use or non-use of contraceptives, the study sought to find out some of the misconceptions about contraceptives in Paga. Misconceptions about side-effects were two of the most prevalent misconceptions among the participants, as 57.48% believed that contraceptives caused infertility, and 45.58% believed using contraceptives would result in cancer. This study findings were similar to findings from Nalwadda, Mirembe, Byamugisha, Faxeli (2010) in Uganda which revealed that young people believed the use of contraceptives interfered with fertility. More so, Campbell et al., (2006) in their reviewed of barriers to fertility regulation showed that perceptions of side effects of contraceptives was viewed from the idea that the pill causes cancer (Campbell et al., 2006). This misconception is especially notable in Paga considering the low levels of education, lack of means of accurate information and the consequent ease of spreading misinformation on contraceptives within the community. It is however important to note that the belief that contraceptives are meant for only married couples was the least common misconception in the study. 5.2 Limitations of the study Firstly, because of the cross sectional nature of the study, different results may be gotten using a different time frame. It is difficult to make causal inferences with a cross sectional study. Also, using the HBM, a woman's attitudes, beliefs, or other individual 63 University of Ghana http://ugspace.ug.edu.gh determinants that dictate her use of contraceptives are not being accounted for. Lastly, the quantitative method that was employed in this study did not allow the researcher to collect in-depth information from the participants. 64 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX CONCLUSIONS AND RECOMMENDATIONS 6.1 Conclusions The study was conducted to determine the barriers to contraceptives use among married women in Paga. The objectives of the study were to identify contraceptives prevalence, assess the knowledge of contraceptives among the participants and to identify the barriers to the use of contraceptives among the participants. This study was guided by the Health Belief Model which assumes that individuals weigh the perceived benefits of a particular health action against the cost of taking the action. Regarding the prevalence of contraceptives among the participants, the findings showed that ever use of contraceptives among the participants was very high as compared to current use. More so, use of any method of contraceptive was high for depo/injectables and the pill. Also, the study results shows that majority of the participants have heard of pill and depo/injectables. Sources of information included friends, health workers and the media through advertisements. The main barriers to non-use of contraceptives were side effects, infertility/difficulty in getting pregnant and hard to get prefered methods. In addition, major barriers for discontinued used included side effects and wanting more children. Misconceptions about contraceptives was also looked at in the study and findings reveals that misconceptions about side effects were most prominent with participants stating contraceptives causes infertility and cancer. Furthermore, the study found that women who belong to age group 25-34 years had higher odds of using contraceptives relative to age group 15-24 years, when education, religion, occupational status, and parity were controlled for. The place of residence, as 65 University of Ghana http://ugspace.ug.edu.gh well, as education were predictors of the use of contraceptives. Those who lived in the urban area are more likely to use than those in the rural areas, just as those who had primary and secondary education had some significantly higher odds of using contraceptives than women uneducated. 6.2 Recommendations 1. Tailored messages should be developed to help reduce the level of misconceptions about contraceptives which would help increase the use of contraceptives. Health workers and friends are the major sources of contraceptive knowledge among the participants, it is therefore important to promote the benefits of contraceptives and address the barriers to use of contraceptives through these groups. 2. Also, side effects came out as a major barrier to the use of contraceptives, it would therefore be important if health workers are well educated on this issues so they can explain the possible side effects of each method of contraceptives and how to deal with the side effects when they come. 3. More so, further research should be conducted to address the barriers for never use of contraceptives among married women. 4. Interventions targeting rural dwelling women, uneducated women, older women and other socially-disadvantaged women are needed. These interventions should be designed in a way that they can easily understand and access the contraceptive methods. 66 University of Ghana http://ugspace.ug.edu.gh REFERENCES Achana, F. S., Bawah, A. A., Jackson, E. F., Welaga, P., Awine, T., Asuo-Mante, E., . . . Phillips, J.F. (2015). Spatial and socio-demographic determinants of contraceptive use in the Upper East region of Ghana. Reproductive Health, 12(1), 29-39. Adanu, R. M., Seffah, J. D., Hill, A. G., Darko, R., Duda, R. B., & Anarfi, J. K. (2009). Contraceptive use by women in Accra, Ghana: results from the 2003 Accra Women's Health Survey. African Journal of Reproductive Health, 13(1), 123- 133. Adongo, P. B., Phillips, J. F., Tapsoba, P., Stone, A., & Tabong, P. (2014). The same contraceptive method but different stories: A comparative qualitative study of the misconceptions associated with contraceptive use in southern and northern Ghana. Paper presented at the Population Association of America 2014 Annual Meeting Program, Boston, MA. http://paa2014.princeton.edu/abstracts/141342 Advocacy for Youth. (2012). Young Women and Long-Acting Reversible Contraception Safe, Reliable, and Cost-Effective Birth Control. Washington, DC: Advocacy for Youth Agyei, W. K., & Migadde, M. (1995). Demographic and sociocultural factors influencing contraceptive use in Uganda. Journal of Biosocial Science, 27(1), 47-60. Ahmed, S., Li, Q., Liu, L., & Tsui, A. O. (2012). Maternal deaths averted by contraceptive use: an analysis of 172 countries. Lancet, 380(9837), 111-125. doi: 10.1016/s0140-6736(12)60478-4 Akujobi, R. (2011). Motherhood in African literature and culture. CLCWeb: Comparative Literature and Culture, 13(1), 2-9. Alaii, J , Nanda, G, & Njeru, A. (2012). Fears, Misconceptions, and Side Effects of Modern Contraception in Kenya. . Washington, DC, USA: FHI 360/C-Change. Ali, A. A., & Okud, A. (2013). Factors affecting unmet need for family planning in Eastern Sudan. BMC Public Health, 13, 102. doi: 10.1186/1471-2458-13-102 Andalón, M., Williams, J., & Grossman, M. (2014). Empowering Women: The Effect of Schooling on Young Women's Knowledge and Use of Contraception. National Bureau of Economic Research Working Paper Series, No. 19961. doi: 10.3386/w19961 Apanga, P. A., & Adam, M. A. (2015). Factors influencing the uptake of family planning services in the Talensi District, Ghana. The Pan African Medical Journal, 20(1), 10. Aryeetey, R., Kotoh, A. M, & Hindin, M. J. (2011). Knowledge, perceptions and ever use of modern contraception among women in the Ga East District, Ghana. African Journal of Reproductive Health, 14(4), 27-32. 67 University of Ghana http://ugspace.ug.edu.gh Asamoah, B. O., Agardh, A., & Östergren, P.O. (2013). Inequality in fertility rate and modern contraceptive use among Ghanaian women from 1988–2008. International Journal for Equity in Health, 12(1), 37-49. doi: info:pmid/23718745 Asfaw, H. M., & Gashe, F. E. (2014). Contraceptive use and method preference among HIV positive women in Addis Ababa, Ethiopia: a cross sectional survey. BMC Public Health, 14(1), 566-576. doi: 10.1186/1471-2458-14-566 Ashford, L. (2003). Unmet Need for Family Planning: Recent Trends and Their Implications for Programs. Policy Brief, Retrieved from http://www.prb.org/pdf/unmetneedfamplan-eng.pdf Asiimwe, J. B., Ndugga, P., Mushomi, J., & Manyenye-Ntozi, J. P. (2014). Factors associated with modern contraceptive use among young and older women in Uganda; a comparative analysis. BMC Public Health, 14, 926-937. doi: 10.1186/1471-2458-14-926 Asiimwe, JB, Ndugga, P, & Mushomi, John. (2013). Socio-demographic factors associated with contraceptive use among young women in comparision with older women in Uganda. DHS Working Papers 2013(95),1-34. Retrieved from http://dhsprogram.com/pubs/pdf/WP95/WP95.pdf Asturias de Barrios, L., Mejia de Rodas, I., Nieves, I., Matute, J., & Yinger, N. (1998). Unmet Need for Family Planning in a Peri-Urban Community of Guatemala City. Washington, DC: International Center for Research on Women. Bawah, A. A. (2002). Spousal communication and family planning behavior in Navrongo: a longitudinal assessment. Studies in Family Planning, 33(2), 185- 194. Bawah, A. A., Akweongo, P., Simmons, R., & Phillips, J. F. (1999). Women's fears and men's anxieties: the impact of family planning on gender relations in northern Ghana. Stud Fam Plann, 30(1), 54-66. Biddlecom, A., & Kantorova, V. (2013). Global trends in contraceptive method mix and implications for meeting the demand for family planning. Paper presented at the XXVII IUSSP International Population Conference Busan, Republic of Korea. http://iussp.org/sites/default/files/event_call_for_papers/Biddlecom&Kantorov a_Global-trends-method-mix_19August2013.pdf Bongaarts, J. (1978). A Framework for Analyzing the Proximate Determinants of Fertility. Population and Development Review, 4(1), 105-132. doi: 10.2307/1972149 Bongaarts, J., & Bruce, J. (1995). The causes of unmet need for contraception and the social content of services. Studies in Family Planning, 26(2), 57-75. Bongaarts, J., & Casterline, J. (2013). Fertility Transition: Is sub-Saharan Africa Different? Population and Development Review, 38 (Supplement 1), 153–168. 68 University of Ghana http://ugspace.ug.edu.gh Brown, W., Ottney, A., & Nguyen, S. (2011). Breaking the barrier: the Health Belief Model and patient perceptions regarding contraception. Contraception, 83(5), 453-458. doi: 10.1016/j.contraception.2010.09.010 Bullough, V.L. (2001). Encyclopedia of Birth Control: ABC-CLIO. Campbell, M., Sahin-Hodoglugil, N. N., & Potts, M. (2006). Barriers to Fertility Regulation: A Review of the Literature. Studies In Family Planning 37(2), 87– 98. Carpenter, C. J. (2010). A Meta-Analysis of the Effectiveness of Health Belief Model Variables in Predicting Behavior. Health Communication, 25(8), 661-669. doi: 10.1080/10410236.2010.521906 Casterline, J. B., Sathar, Z. A., & Al-Haque, M. (2001). Obstacles to Contraceptive Use in Pakistan: A Study in Punjab. Studies In Family Planning 32(2), 95-110. Centers for Disease Control and Prevention, . (2014, October 14, 2014). Contraception: How effective are birth control methods? Retrieved 10 November, 2014, from http://www.cdc.gov/reproductivehealth/unintendedpregnancy/contraception.ht m Champion, V. L., & Skinner, C. S. (2008). The health belief model. Health behavior and health education: Theory, research, and practice, 4, 45-65. Chuang, Cynthia H., Chase, Gary A., Bensyl, Diana M., & Weisman, Carol S. (2005). Contraceptive use by diabetic and obese women. Women's Health Issues, 15(4), 167-173. doi: http://dx.doi.org/10.1016/j.whi.2005.04.002 Ciszewski, R. L., & Harvey, P. D. (1994). The effect of price increases on contraceptive sales in Bangladesh. Journal of Biosocial Science, 26(1), 25-35. Cleland, J., Bernstein, S., Ezeh, A., Faundes, A., Glasier, A., & Innis, J. (2006). Family planning: the unfinished agenda. The Lancet, 368(9549), 1810-1827. doi: http://dx.doi.org/10.1016/S0140-6736(06)69480-4 Cochran, W. G. (1977). Sampling techniques. New York: John Wiley and Sons. Creanga, A. A., Gillespie, D., Karklins, S., & Tsui, A. O. (2011). Low use of contraception among poor women in Africa: an equity issue. Bulletin of the World Health Organization, 89(4), 258-266. Darroch, J. E., Sedgh, G., & Ball, H. (2011). Contraceptive Technologies: Responding to Women's Needs (pp. 1-52). Retrieved from http://www.guttmacher.org/pubs/Contraceptive-Technologies.pdf Darroch, J. E., & Singh, S. (2013). Trends in contraceptive need and use in developing countries in 2003, 2008, and 2012: an analysis of national surveys. Lancet, 381(9879), 1756-1762. doi: 10.1016/s0140-6736(13)60597-8 Debpuur, C., Phillips, J. F., Jackson, E. F., Nazzar, A., Ngom, P., & Binka, F. N. (2002). The Impact of the Navrongo Project on Contraceptive Knowledge and Use, Reproductive Preferences, and Fertility. Studies in Family Planning, 33(2), 141- 164. doi: 10.1111/j.1728-4465.2002.00141.x 69 University of Ghana http://ugspace.ug.edu.gh Doctor, H V., Phillips, J. F., & Sakeah, E. (2009). The Influence of Changes in Women's Religious Affiliation on Contraceptive Use and Fertility Among the Kassena- Nankana of Northern Ghana. Studies in Family Planning, 40(2), 113-122. doi: 10.1111/j.1728-4465.2009.00194.x Edouard, L. (2009). The right to contraception and the wrongs of restrictive services. Int J Gynaecol Obstet, 106(2), 156-159. doi: 10.1016/j.ijgo.2009.03.030 Parnell, A.M. & National Research Council (US) (1989). Contraceptive Use and Controlled Fertility:: Health Issues for Women and Children: National Academies Press. El-Zanaty, F., Way, A., Kishor, S., & Casterline, J. B., (1999.). Egypt Indepth Study on the Reasons for Nonuse of Family Planning. Cairo: National Population Council. Family Planning Association UK. (2010). Contraception: past, present and future. Factsheet, 1-6. Retrieved from Sexual Health Direct website: Family Planning Queensland. (2005). Natural Methods of Birth Control Contraception (pp. 1-4). Queensland, Australia: Family Planning Queensland. Farid-ul-Hasnain, S., Johansson, E., Gulzar, S., & Krantz, G. (2013). Need for multilevel strategies and enhanced acceptance of contraceptive use in order to combat the spread of HIV/AIDS in a Muslim society: a qualitative study of young adults in urban Karachi, Pakistan. Global Journal of Health Sciences, 5(5), 57-66. doi: 10.5539/gjhs.v5n5p57 Frohwirth, L., Moore, A. M., & Maniaci, R. (2013). Perceptions of susceptibility to pregnancy among U.S. women obtaining abortions. Social Science & Medicine, 99(0), 18-26. doi: http://dx.doi.org/10.1016/j.socscimed.2013.10.010 Frost, J. J., & Darroch, J. E. (2008). Factors Associated with Contraceptive Choice and Inconsistent Method Use, United States, 2004. Perspectives on Sexual and Reproductive Health, 40(2), 94-104. doi: 10.1363/4009408 Frost, J. J., Lindberg, L. D., & Finer, L. B. (2012). Young Adults' Contraceptive Knowledge, Norms and Attitudes: Associations with Risk Of Unintended Pregnancy. Perspectives on Sexual and Reproductive Health, 44(2), 107-116. doi: 10.1363/4410712 Ghana Statistical Service (GSS). (2006). Women and men in Ghana: a statistical compedium. Accra, Ghana: Ghana Statistical Service Ghana Statistical Service (GSS). (2009). Demographic and Health Survey 2008. Accra, Ghana: ICF Macro, Calverton, Maryland, U.S.A. Ghana Statistical Service (GSS). (2015). Demographic and Health Survey 2014: Key Findings. Accra, Ghana: ICF Macro, Calverton, Maryland, U.S.A. Greene, E., & Stanback, J. (2012). Old barriers need not apply: opening doors for new contraceptives in the developing world. Contraception, 85(1), 11-14. doi: 10.1016/j.contraception.2011.05.004 70 University of Ghana http://ugspace.ug.edu.gh Gribble, J. (2008). Family Planning in West Africa. The BRIDGE Project. http://www.prb.org/Publications/Articles/2008/westafricafamilyplanning.aspx Guttmacher Institute. (2010). Facts on Barriers to Contraceptive Use In the Philippines In Brief (pp. 1-4). New York, NY: Guttmacher Institute, Likhaan. Haddad, L. B., Polis, C. B., Sheth, A. N., Brown, J., Kourtis, A. P., King, C., . . . Ofotokun, I. (2014). Contraceptive Methods and Risk of HIV Acquisition or Female-to-Male Transmission. Current HIV/AIDS Report doi: 10.1007/s11904- 014-0236-6 Heinemann, K., Saad, F., Wiesemes, M., White, S., & Heinemann, L. (2005). Attitudes toward male fertility control: results of a multinational survey on four continents. Hum Reprod, 20(2), 549-556. doi: 10.1093/humrep/deh574 Hochbaum, G. M. (1958). Public Participation in Medical Screening Programs: A Socio-Psychological Study, (Vol. PHS Publication no 572 ). Washington, DC: US Government Printing Office. Jones, R. K. (2011). Beyond Birth Control: The Overlooked Benefits Of Oral Contraceptive Pills. In Jared Rosenberg (Ed.). New York: Guttmacher Institute. Karavus, M., Cali, S., Kalaca, S., & Cebeci, D. (2004). Attitudes of married individuals towards oral contraceptives: a qualitative study in Istanbul, Turkey. Journa; of Family Planning and Reproductive Health Care, 30(2), 95-98. Kershaw, T. S., Niccolai, L. M., Ethier, K. A., Lewis, J. B., & Ickovics, J. R. (2003). Perceived susceptibility to pregnancy and sexually transmitted disease among pregnant and nonpregnant adolescents. Journal of Community Psychology, 31(4), 419-434. Khan, S., Mishra, V., Arnold, F., & Abderrahim, N. (2007). Contraceptive trends in developing countries DHS Reports. Calverton Maryland: Macro International MEASURE DHS 2007 Dec. Kirtley, S., Murray, C., & Kennedy, S. (2009). Women’s health—what’s new worldwide. BJOG: An International Journal of Obstetrics & Gynaecology, 116(13), 1826-1828. doi: 10.1111/j.1471-0528.2009.02441.x Levin, A., Amin, A., Rahman, A., Saifi, R., Khuda, B. E. & Mozumder, K. (1999). Cost-effectiveness of family planning and maternal health service delivery strategies in rural Bangladesh. International Journal of Health Planning and Management, 14(3), 219-233. doi: 10.1002/(sici)1099- 1751(199907/09)14:3<219::aid-hpm549>3.0.co;2-n Link, C. F. (2011). Spousal communication and contraceptive use in rural Nepal: an event history analysis. Studies in family planning, 42(2), 83-92. Lwelamira, J, Mnyamagola, G , & Msaki, M. M. (2012). Knowledge, Attitude and Practice (KAP) Towards Modern Contraceptives Among Married Women of Reproductive Age in Mpwapwa District, Central Tanzania. Current Research Journal of Social Sciences, 4(3), 235-245. 71 University of Ghana http://ugspace.ug.edu.gh Matheny, G. (2004). Family planning programs: getting the most for the money. International Family Planning Perspectives, 30(3), 134-138. doi: 10.1363/ifpp.30.134.04 Maurice, M. J. (2007). Intention to Use Contraception and Subsequent Contraceptive Behavior. (Master of Science in the Field of Population Based Field Epidemiology Research Report), University of the Witwatersrand, South Africa, Johannesburg, South Africa. Meka, I. A., Okwara, E. C., & Meka, A. O. (2013). Contraception among bankers in an urban community in Lagos state, Nigeria. The Pan African Medical Journal, 14. doi: 10.11604/pamj.2013.14.80.2216 Mekonnen, W., & Worku, A. (2011). Determinants of low family planning use and high unmet need in Butajira District, South Central Ethiopia. Reproductive Health, 8, 37-45. doi: 10.1186/1742-4755-8-37 Meskele, M., & Mekonnen, W. (2014). Factors affecting women's intention to use long acting and permanent contraceptive methods in Wolaita Zone, Southern Ethiopia: a cross-sectional study. BMC Womens Health, 14, 109-118. doi: 10.1186/1472-6874-14-109 Mohammed, A, Woldeyohannes, D., Feleke, A., & Megabiaw, B. (2014). Determinants of modern contraceptive utilization among married women of reproductive age group in North Shoa Zone, Amhara Region, Ethiopia. Reproductive Health, 11, 13-20. doi: 10.1186/1742-4755-11-13 Mon, M. M, & Liabsuetrakul, T. (2012). Predictors of Contraceptive Use Among Married Youths and Their Husbands in a Rural Area of Myanmar. Asia-Pacific Journal of Public Health, 24(1), 151-160. doi: 10.1177/1010539510381918 Myer, L., Mlobeli, R., Cooper, D., Smit, J., & Morroni, C. (2007). Knowledge and use of emergency contraception among women in the Western Cape province of South Africa: a cross-sectional study. BMC Womens Health, 7, 14-23. doi: 10.1186/1472-6874-7-14 Nalwadda, G., Mirembe, F., Byamugisha, J., & Faxelid, E. (2010). Persistent high fertility in Uganda: young people recount obstacles and enabling factors to use of contraceptives. BMC Public Health, 10, 530-542. doi: 10.1186/1471-2458- 10-530 National Population Council. (1994). National population policy, (Revised Edition, 1994). In Government of Ghana (Ed.), National population policy (pp. 1-10). Accra, Ghana: National Population Council. National Prescribing Service. (2007). Hormonal contraceptives: tailoring for the individual National Prescribing Service Newsletter (pp. 1-6). New South Wales, Australia. Neetu, J. A, Assefa, S., Meselech, A. R., & Tsui, A. O. (2015). Does a Couple’s Marital Quality Influence the Quality of their Contraceptive Use? PAA Princeton(151606), 1-34. 72 University of Ghana http://ugspace.ug.edu.gh Nonvignon, Justice, & Novignon, Jacob. (2014). Trend and determinants of contraceptive use among women of reproductive age in Ghana. African Population Studies, 28(2), 956-967. Ochako, R., Mbondo, M., Aloo, S., Kaimenyi, S., Thompson, R., Temmerman, M., & Kays, M. (2015). Barriers to modern contraceptive methods uptake among young women in Kenya: a qualitative study. BMC public health, 15(1), 118- 129. Ogunjuyigbe, P. O., Ojofeitimi, E. O., & Liasu, A. (2009). Spousal communication, changes in partner attitude, and contraceptive use among the Yorubas of Southwest Nigeria. Indian journal of community medicine: official publication of Indian Association of Preventive & Social Medicine, 34(2), 112-124. Olalekan, Adebimpe Wasiu, & Olufunmilayo, Asekun-Olarinmoye Esther. (2012). A Comparative Study of Contraceptive Use among Rural and Urban Women in Osun State, Nigeria. Opoku, B. (2010). Contraceptive use among 'at-risk' women in a metropolitan area in Ghana. Acta Obstetrics and Gynecology of Scandinavia, 89(8), 1105-1107. doi: 10.3109/00016341003801672 Pacqué-Margolis, S., Cox, C., Puckett, A., & Schaefer, L. (2013). Exploring Contraceptive Use Differentials in Sub-Saharan Africa through a Health Workforce Lens. Technical Brief #11 (11th ed.). Washington DC: CapacityPlus and USAID. Pearson, E., & Becker, S. (2014). Couples' unmet need for family planning in three west african countries. Studies in Family Planning, 45(3), 339-359. doi: 10.1111/j.1728-4465.2014.00395.x Planned Parenthood Federation of America. (2012). A History of Birth Control Methods. In Jon Knowles (Ed.), (pp. 1-16). New York, NY: Planned Parenthood Federation of America. Population Reference Bureau (PRB). (2014). 2014 World Population Data Sheet. In Carl Haub & Toshiko Kaneda. (Eds.), (pp. 1-20). Washington, DC Population Reference Bureau Rahman, M., Berenson, A. B., & Herrera, S. R. (2013). Perceived susceptibility to pregnancy and its association with safer sex, contraceptive adherence and subsequent pregnancy among adolescent and young adult women. Contraception, 87(4), 437-442. Raine, T. R, Harper, C. C, Rocca, C. H, Fischer, R, Padian, N., Klausner, J. D, & Darney, P. D. (2005). Direct access to emergency contraception through pharmacies and effect on unintended pregnancy and STIs: a randomized controlled trial. Jama, 293(1), 54-62. Ricci, S. S., & Kyle, T. (2014). Maternity and Pediatric Nursing. Riverwoods, IL: Lippincott Williams & Wilkins. 73 University of Ghana http://ugspace.ug.edu.gh Roberts, A., & Noyes, J. (2009). Contraception and women over 40 years of age: mixed-method systematic review. Journal of Advanced Nursing, 65(6), 1155- 1170. doi: 10.1111/j.1365-2648.2009.04976.x Robinson, N., Moshabela, M., Owusu-Ansah, L., Kapungu, C., & Geller, S. (2014). Barriers to Intrauterine Device Uptake in a Rural Setting in Ghana. Health Care for Women International, 1-19. doi: 10.1080/07399332.2014.946511 Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1988). Social learning theory and the Health Belief Model. Health Education Quarterly, 15(2), 175-183. Roudi-Fahimi, F. (2003). Women's reproductive health in the Middle East and North Africa: Population Reference Bureau Washington, DC. Sahu, B., & Hutter, I. (2012). 'Lived Islam' in India and Bangladesh: negotiating religion to realise reproductive aspirations. Culture, Health and Sexuality, 14(5), 521-535. doi: 10.1080/13691058.2012.672652 Sedgh, G., & Hussain, R. (2014). Reasons for Contraceptive Nonuse among Women Having Unmet Need for Contraception in Developing Countries Studies in Family Planning, 45(2), 151–169. Sedgh, G., Hussain, R., Bankole, A., & Singh, S. (2007). Women with an unmet need for contraception in developing countries and their reasons for not using a method: Alan Guttmacher Institute. Seltzer, J. R. (2002). The Origins and Evolution of Family Planning Programs in Developing Countries. Santa Monica, CA: RAND. Shelton, J. D., Angle, M. A., & Jacobstein, R. A. (1992). Medical barriers to access to family planning. Lancet, 340(8831), 1334-1335. Sivin, I., & Batár, I. (2010). State-of-the-art of non-hormonal methods of contraception: III. Intrauterine devices. The European Journal of Contraception and Reproductive Health Care, 15(2), 96-112. Solo, J, Odonkor, M, Pile, J. M., & Wickstrom, J. ( 2005). Repositioning Family Planning-Ghana Case Study: "Give them the power." Retrieved from http://www.acquireproject.org/fileadmin/user_upload/ACQUIRE/Ghana_case _study.pdf Speizer, I. , Hotchkiss, D. , Magnani, R. , Hubbard, B , & Nelson, K. (2000). Do Service Providers in Tanzania Unnecessarily Restrict Clients’ Access to Contraceptive Methods? International Family Planning Perspectives, 26(1), 13-20. Tawiah, E. O. (1997). Factors affecting contraceptive use in Ghana. Journal of Biosocial Scicence, 29(2), 141-149. The American College of Obstetricians and Gynecologists. (2014). Barrier Methods of Birth Control: Diaphragm, Sponge, Cervical Cap, and Condom Frequently Asked Questions FAQ (Vol. Contraception): The American College of Obstetricians and Gynecologists (ACOG). 74 University of Ghana http://ugspace.ug.edu.gh Trussell, J., Raymond, E. G., & Cleland, K. (2014). Emergency Contraception: A Last Chance to Prevent Unintended Pregnancy. Retrieved from The Emergency Contraception Website website: http://ec.princeton.edu/questions/ec- review.pdf United Nations (UN). (2013). World Contraceptive Patterns 2013 (Department of Economic and Social Affairs & Population Division, Trans.) ST/ESA/SER.A/326 New York: United Nations. United Nations (UN). (2014). World Population Prospects: The 2012 Revision, Methodology of the United Nations Population Estimates and Projections, (Department of Economic and Social Affairs & Population Division, Trans.) Working Paper No. ESA/P/WP.235.: United Nations. United States Agency for International Development (USAID). (2007). Contraceptive Trends In Developing Countries. In Shane Khan, Vinod Mishra, Fred Arnold & Noureddine Abderrahim. (Eds.), DHS COMPARATIVE REPORTS 16 (Vol. 16, pp. 1-86). Calverton, MD: United States Agency for International Development (USAID), . Vathiny, O. V., & Hourn, K. K. (2009). Barriers to contraceptive use in Cambodia Cambodia Research Case study. Phnom Penh: Reproductive Health Association of Cambodia (RHAC). World Health Organization (WHO) (2014). Trends in Maternal Mortality: 1990 to 2013 (Vol. Executive Summary, pp. 12). Geneva: World Health Organization. Wusu, O. (2014). Religious influence on non-use of modern contraceptives among women in Nigeria: Comparative analysis of 1990 and 2008 NDHS. J Biosoc Sci, 1-20. doi: 10.1017/s0021932014000352 Yinger, N. (1998). Unmet Need for Family Planning: Reflecting Women’s Perceptions. Washington, DC: International Center for Research on Women. 75 University of Ghana http://ugspace.ug.edu.gh APPENDICES APPENDIX 1 INFORMED CONSENT FORM University of Ghana, School of Public Health Department of Population, Family and Reproductive Health CONSENT FORM Consent to participate in study: Hello. My name is Nafisatu Sulemana. I am doing a research on barriers to contraceptive use among married women in Paga. Aim of the study To identify the barriers to contraceptives use among married women in Paga. What Participants are required to do? If you agree to take part in this study, you are required to answer a series of questions that have been prepared for the study through interview to help the researcher obtain the intended information. You will be interviewed for 20-30 minutes. Privacy and Confidentiality All information that will be collected from you will be kept only with me under lock and key, and will be used only for this study. The form will not bear your name and other personal things that can lead to you. Possible Risk and Discomfort Some questions related to your reproductive health and making decision for contraceptive use may possibly seem sensitive and uncomfortable, and I will make all possible efforts to minimize such discomfort in asking the questions. You may however decline to answer any question you deem uncomfortable. 76 University of Ghana http://ugspace.ug.edu.gh Rights to Withdraw and Alternatives Your participation in this study is completely voluntary. You can decide not to participate in this study and even if you have already accepted to take part in the study, you can quit at any time if you feel like. Refusal to participate, withdrawal from the study or decision not to answer any question will not involve penalty or loss of any benefits. Who to contact If you ever have any questions concerning this study, you should contact the Principal Investigator Nafisatu Sulemana, from University of Ghana, School of Public Health. Mobile phone number; 0248276156. If there is the need for further clarification, as a participant you have a right to call the principal investigator, or Dr. Ayaga A. Bawa on 0244714164 who is the supervisor of this study. If you ever need any more clarifications, you also have the right as a participant to contact Hannah Frimpong from the Ghana Ethical Review Committee on 0243235225 or 0507041223. Do you agree? Yes, I have read/ heard the content of the consent form and agree to participate in this study Signature:_______________ Thumb-Print: Date of signed consent: _____________ 77 University of Ghana http://ugspace.ug.edu.gh APPENDIX 2 QUESTIONNAIRE FOR RESEARCH ON BARRIERS TO CONTRACEPTIVES USE AMONG MARRIED WOMEN AGED 15-49 IN PAGA Dear Respondent, This research is being carried out to identify the barriers affecting contraceptives use among married women aged 15-49 in Paga. I would therefore like to take a little of your time for you to answer the following questions. I assure you that, the information you will provide will be strictly kept confidential and will not be hold against you in any way. Respondent ID Number House number [ ] [ ] [ ] [ ] [ ] [ ] Place of Residence (urban, sub- urban, rural) Interviewee ID Number ID number [ ] [ ] [ ] Date of administration of Day Month Year Questionnaire [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Interview Consent has been YES…….. [ ] read to participant NO…….... [ ] IF NO, READ CONSENT Consent has been obtained IF YES, CONTINUE IF NO, END 78 University of Ghana http://ugspace.ug.edu.gh A. SOCIO-DEMOGRAPHIC CHARACTERISTICS Questions Response and Coding Skips 1. Age [ ] [ ] 2 Educational Yes No Status Formal education……………………… 1 2 No formal education…………………... 1 2 If Yes, skip to 4 3. Please state Yes No Primary……………………………....... 1 2 JSS/Middle……………………………. 1 2 Secondary……………………………... 1 2 Vocational/Technical………...……....... 1 2 Tertiary………………………………... 1 2 4. Occupational Yes No Status Employed………………………………. 1 2 Unemployed……………………………. 1 2 5. Please state Yes No occupation Farming…………………………………. 1 2 Petty trading…………………………...... 1 2 Teaching………......................................... 1 2 Police Officer……………………………. 1 2 Health Worker…………………………… 1 2 Banking………………………………….. 1 2 Housewife……………………………….. 1 2 Hairdressing……………………………... 1 2 Apprentice……………………………….. 1 2 Seamstress……………………………….. 1 2 Female Porter…………………………….. 1 2 Other (Specify)……………………………. 1 2 79 University of Ghana http://ugspace.ug.edu.gh 6 Religion Christian………………………………….. 1 Muslim…………………………………… 2 Traditionalist…………………………….. 3 80 University of Ghana http://ugspace.ug.edu.gh B. KNOWLEDGE ON CONTRACEPTIVES Questions Response and Coding Skips 1. Have you heard of Yes……………………………... 1 contraception or No…………………………........ 2 If No, family planning? skip to 3 2 Which ways or Yes No methods have you Tubal Ligation (Female sterilization)… 1 2 heard that a couple Vasectomy (Male sterilization)……… 1 2 can use to delay or Pill………………………………… 1 2 avoid pregnancy? IUD (Intra Uterine Device)……….. 1 2 (tick all that apply) Depo/ Norigynon (Injectables)..…… 1 2 Jadelle (Implants)…………………. 1 2 (DO NOT READ Male condom……………………… 1 2 OUT) Female condom…………………… 1 2 Diaphragm………………………… 1 2 Foam or jelly……………………… 1 2 Emergency Contraception………… 1 2 Lactational Amenorrhoea Method… 1 2 Withdrawal………………………... 1 2 Rhythm/Calendar method………. 1 2 Other (specify)……………....… 1 2 3 Have you or your Yes………………………………….. 1 partner ever used No…………………………………... 2 If anything to prevent No, pregnancy? skip to 9 4 Which methods did Yes No you use? Tubal Ligation (Female sterilization)… 1 2 (tick all that apply) Vasectomy (Male sterilization)……… 1 2 Pill………………………………… 1 2 IUD (Intra Uterine Device)……….. 1 2 (DO NOT READ Depo/ Norigynon (Injectables)..…… 1 2 OUT) Jadelle (Implants)…………………. 1 2 Male condom……………………… 1 2 Female condom…………………… 1 2 Diaphragm………………………… 1 2 Foam or jelly……………………… 1 2 Emergency Contraception………… 1 2 Lactational Amenorrhoea Method…… 1 2 Withdrawal………………………... 1 2 Rhythm/Calendar method…………. 1 2 Other (specify)……………....…….. 1 2 5 Did you discuss with Yes………………………………….. 1 your partner before No…………………………………... 2 using this method? 81 University of Ghana http://ugspace.ug.edu.gh 6 Why are you using Yes No family planning? For spacing births………………….. 1 2 For limiting / stopping number of children…………………. 1 2 For treating Infertility………………. 1 2 For treating menstrual Irregularity…. 1 2 Other (specify)……………………… 1 7 Where did you obtain Yes No the method? Gov’t hospital………………………. 1 2 Gov’t health centre…………………. 1 2 Gov’t health post/CHPS……………. 1 2 Family Planning Clinic……………... 1 2 Mobile Clinic……………………….. 1 2 Field Worker/ Outreach/ Peer Educator…………………………….. 1 2 Private Hospital/Clinic……………… 1 2 Pharmacy/Chemical Drug Store…….. 1 2 Other (Specify)……………………… 1 2 8 What informed your Yes No decision to use Because my friend uses…………….. 1 2 contraceptives? Advice from a health worker……….. 1 2 (tick all that apply) I cannot take care of children……….. 1 2 I have enough children………………. 1 2 Advertisement (radio, TV etc.)………. 1 2 Other (specify)……………………….. 1 2 9 Why have you not Yes No used any method? Religious belief…………………….... 1 2 (tick all that apply) Distance to acquisition of Contraceptives……………………….. 1 2 Partner opposed to using…………….. 1 2 Family members opposed to using it… 1 2 Side effects…………………………… 1 2 Difficult to get pregnant/infertility…… 1 2 Hard to get preferred methods……….. 1 2 Too costly……………………………. 1 2 Want more children………………….. 1 2 Attitude of service providers……….... 1 2 Other (Specify)……………………… 1 2 82 University of Ghana http://ugspace.ug.edu.gh C. PERCEIVED BARRIERS Questions Response and Coding Skips 1 Do you or your partner Yes……………………………... 1 still use No…………………………........ 2 If No, contraceptives? skip to 13 2 Which method are you Traditional……………………………... 1 currently using? Modern……………………………........ 2 If Modern, skip to 4 3 Which traditional Yes No method are you Withdrawal………………………... 1 2 currently using? Rhythm/Calendar method…………. 1 2 Other (Specify)…………………….. 1 2 4 Which modern method Yes No are you currently Tubal Ligation (Female sterilization)… 1 2 using? Vasectomy (Male sterilization)……… 1 2 Pill………………………………… 1 2 IUD (Intra Uterine Device)……….. 1 2 Depo/ Norigynon (Injectables)..…… 1 2 Jadelle (Implants)…………………. 1 2 Male condom……………………… 1 2 Female condom…………………… 1 2 Diaphragm………………………… 1 2 Foam or jelly……………………… 1 2 Emergency Contraception………… 1 2 Lactational Amenorrhoea Method… 1 2 Other (specify)……………....…….. 1 2 5 The last time you used Yes………………………………….. 1 a method, did you pay No…………………………………... 2 any amount of money? Don’t know/cannot remember……..... 3 (Including payment for the method and any consultation you may have had) 6 Was your preferred Yes………………………………….. 1 method available? No…………………………………... 2 7 Did you like the Yes………………………………….. 1 method you finally No…………………………………... 2 chose? 8 Were you told about Yes………………………………….. 1 the side effects or No…………………………………... 2 problems you might have with the method? 83 University of Ghana http://ugspace.ug.edu.gh 9 Were you told what to Yes………………………………….. 1 do if you experience No…………………………………... 2 side effects or problems? 10 Did the service Yes………………………………….. 1 provider ask you to do No…………………………………... 2 any laboratory test (example urine test) before providing the service? 11 Were you asked to Yes………………………………….. 1 bring your husband No…………………………………... 2 before your preferred choice or method provided? 12 Why did you stop Yes No using contraceptives? Religious belief…………………….... 1 2 (tick all that apply) Distance to acquisition of Contraceptives……………………….. 1 2 Partner opposed to using…………….. 1 2 Family members opposed to using it… 1 2 Side effects…………………………… 1 2 Difficult to get pregnant/infertility…… 1 2 Hard to get preferred methods……….. 1 2 Too costly……………………………. 1 2 Want more children………………….. 1 2 Attitude of service providers……….... 1 2 Other (Specify)……………………… 1 2 Fear of ancestral punishment………... 1 2 Because of menopause…………….… 1 2 Other (Specify)…………………......... 1 2 13 Why will you not use Yes No any method of Religious belief…………………….... 1 2 contraceptives? (tick Distance to acquisition of Contraceptives……………………….. 1 2 all that apply) Partner opposed to using…………….. 1 2 Family members opposed to using it… 1 2 Side effects…………………………… 1 2 Difficult to get pregnant/infertility…… 1 2 Hard to get preferred methods……….. 1 2 Too costly……………………………. 1 2 Want more children………………….. 1 2 Attitude of service providers……….... 1 2 Other (Specify)……………………… 1 2 Fear of ancestral punishment………... 1 2 Because of menopause…………….… 1 2 Other (Specify)…………………......... 1 2 84 University of Ghana http://ugspace.ug.edu.gh D. PERCEIVED SUSCEPTIBILITY Questions Response and Coding Skip 1 Do you know the importance of Yes…………………… 1 contraceptives? No…………………… 2 If No, skip to 3 2 What are the importance of Yes No contraceptives? Prevents unwanted (tick all that apply) Pregnancy……………… 1 2 Prevents STIs…………… 1 2 Reduces repeated child-birth………………. 1 2 Improves the health of the mother……………… 1 2 Use of contraceptives results in economic benefits 1 2 Other (specify)…………… 1 2 3 How many children do you have? None……………………… 1 1-4..…………………… 2 5-8……………………… 3 Above 8………………… 4 4 Did you plan to have these Yes…………………………….. 1 children the time they arrived? No……………………………... 2 5 Do you think you are susceptible Yes No to the following? Unwanted pregnancy….. 1 2 (tick all that apply) Contraction of STIs…… 1 2 Repeated child birth affecting your health…... 1 2 Repeated child birth draining your income….. 1 2 Repeated child birth Affects the quality of life of your children……….. 1 2 Abortion………………. 1 2 Other (specify)………… 1 2 85 University of Ghana http://ugspace.ug.edu.gh E. PERCEIVED SEVERITY Questions Response and Coding Skips 1 Have you ever been pregnant? Yes…………………………….. 1 No……………………………... 2 If No, skip to 5 2 Are all your children currently Yes…………………………….. 1 staying with you? No……………………………... 2 3 How many of them are None……………………… 1 currently staying with you? 1-4..……………………… 2 5-8……………………… 3 Above 8…………………… 4 4 Are you able to take care of Yes…………………………….. 1 all your children? No……………………………... 2 5 Do you think there is the need Yes…………………………….. 1 to use contraceptives? No……………………………... 2 6 There is the need for Yes No contraceptives to…. Prevent unwanted (tick all that apply) Pregnancy…………….…. 1 2 Prevent STIs…………….. 1 2 Reduce repeated child-birth………………... 1 2 Improve the health of the mother……………….. 1 2 Obtain economic benefits Other (specify)…………… 1 2 86 University of Ghana http://ugspace.ug.edu.gh F. MISCONCEPTIONS ABOUT CONTRACEPTIVES Please make some general statements about contraception methods. I would like to know if you agree or disagree with the following statements. If you agree, tick YES and if you disagree tick NO. Questions Response and Coding Skips 1 Use of contraceptives can lead Yes…………………………….. 1 No……………………………... 2 to infertility among women Don’t Know…………………… 3 2 Contraceptive methods Yes…………………………….. 1 No……………………………... 2 encourage women to be Don’t Know…………………… 3 promiscuous 3 Condoms encourage male Yes…………………………….. 1 No……………………………... 2 infidelity Don’t Know…………………… 3 4 Contraceptives causes cancer Yes…………………………….. 1 No……………………………... 2 or other diseases Don’t Know…………………… 3 5 Contraceptives is only meant Yes…………………………….. 1 No……………………………... 2 for married people Don’t Know…………………… 3 Thank you 87