SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA MODERN CONTRACEPTIVE USE AMONG YOUNG WOMEN IN BUDUMBURAM REFUGEE CAMP IN GHANA BY DORIS AMOAKO JNR (10263049) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON, IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH (MPH) DEGREE JULY, 2016 University of Ghana http://ugspace.ug.edu.gh i DECLARATION I, Doris Amoako Jnr hereby declare that except for other people’s works which have been duly acknowledged, this work is the result of my own original work under supervision. _________________________________ DORIS AMOAKO JNR (STUDENT) DATE ------------------------------------------- __________________________________ DR. JOHN KUUMUORI GANLE (ACADEMIC SUPERVISOR) DATE -------------------------------------------- ` University of Ghana http://ugspace.ug.edu.gh ii DEDICATION This piece of work is dedicated to my dearest husband Felix Nii Teiko Sackey; my children Felix Nii Kwashie-Kojo Sackey and Benjamin Emmanuel Nii Kwashie-Kojo Kuma Sackey; nephew Evans Twum as well as my house help Gertrude Kessewa. University of Ghana http://ugspace.ug.edu.gh iii ACKNOWLEDGEMENT My first and foremost thanks go to God Almighty for without him this would not have been possible. My sincere appreciation to my supervisor Dr. John Kuumuori Ganle for the encouragement, support, guidance and patience he offered throughout the study. To the dean of the school Prof. Richard Adanu, the Head of Department, Prof. Augustine Ankomah, Prof. Adongo and Dr. Benjamin Ayittey, I say a big thank you for your countless advice and support. I will also want to acknowledge the people of Budumburam refugee camp for their cooperation without which this work could not have been done. I owe a special gratitude to my family, especially my loving husband, Felix Nii Teiko Sackey who has always been there for me in various ways through his encouragement, support to take me further in life and advised me to apply for this master’s programme. To my precious children, Felix Sackey and Benjamin Sackey, my nephew Evans Twum as well as Gertrude Kessewa who have always been for me. My sincere thanks goes to Col. Ivy Tamakloe, Lt.Col Akatu, DDNS Oteng Paulina and staff midwife Juliet Inkoom for their encouragement for the success of the programme. To my colleagues, research assistants and friends Mr Samuel Amabley, Mr Aboagye Dacosta, Augustine Annan, Bernard Asiamah-yeboah, Mr. Morgan, Aunty Comfort and Kombat, Charity, Nana Tiwaa, Joshua Asiedu, Muniratu and Kofi Dennis; I say thank you all for been there with your assistance and encouragement. To all individuals who contributed in one way or the other, I say thank you all for being there with your assistance and encouragement. University of Ghana http://ugspace.ug.edu.gh iv TABLE OF CONTENTS DECLARATION .................................................................................................................. i DEDICATION .................................................................................................................... ii ACKNOWLEDGEMENT ................................................................................................. iii TABLE OF CONTENTS ................................................................................................... iv LIST OF TABLES ............................................................................................................ vii LIST OF FIGURES ......................................................................................................... viii LIST OF ABBREVIATION ............................................................................................... ix ABSTRACT ........................................................................................................................ x CHAPTER ONE .................................................................................................................. 1 INTRODUCTION .......................................................................................................... 1 1.0 Background ............................................................................................................... 1 1.1 Problem Statement .................................................................................................... 3 1.2 Objectives.................................................................................................................. 4 1.3 Research Questions ................................................................................................... 5 1.4 Justification of the Study........................................................................................... 5 1.5 Conclusion ................................................................................................................ 6 CHAPTER TWO ................................................................................................................. 7 LITERATURE REVIEW .................................................................................................... 7 2.1 Definition and types of contraceptive ....................................................................... 7 2.1.1 Barrier method ....................................................................................................... 7 2.1.2 Hormonal Methods ............................................................................................. 8 2.1.3 Sterilization ...................................................................................................... 10 2.1.4 Natural methods ............................................................................................... 10 2.1.5 Post-coital contraception .................................................................................. 11 2.2 Awareness and Knowledge of modern contraceptive use among young women ... 11 2.3 Attitudes towards modern contraceptives ............................................................... 13 2.4 Factors influencing modern contraceptives use among young women .................. 13 2.5 Conclusion .............................................................................................................. 15 2.6 Conceptual framework ............................................................................................ 16 University of Ghana http://ugspace.ug.edu.gh v CHAPTER THREE ........................................................................................................... 19 METHODS ........................................................................................................................ 19 3.0 Introduction ............................................................................................................. 19 3.1 Study design ............................................................................................................ 19 3.2 Study area ................................................................................................................ 19 3.3 Study Population ..................................................................................................... 21 3.3.1 Inclusion criteria ............................................................................................... 21 3.3.2 Exclusion criteria .............................................................................................. 21 3.4 Sample size determination ...................................................................................... 22 3.5 Sampling methods ................................................................................................... 23 3.6 Data collection methods and instruments ............................................................... 23 3.7 Quality assurance .................................................................................................... 24 3.8. Data Entry and Processing ................................................................................. 24 3.9 Data Analysis .......................................................................................................... 25 3.9.1 Variables ........................................................................................................... 25 3.9.2 Data Processing and Analysis .......................................................................... 25 3.10 Ethical consideration ............................................................................................. 26 3.11 Conclusion ............................................................................................................ 27 CHAPTER FOUR ............................................................................................................. 28 RESULTS .......................................................................................................................... 28 4.1 Introduction ............................................................................................................. 28 4.2 Socio-demographic characteristics of the respondents ........................................... 28 4.3 Awareness and knowledge of contraceptive methods ............................................ 30 4.4 Attitude toward modern contraceptive use ............................................................. 32 4.5 Socio-demographic characteristics of women who ever used contraceptives ........ 34 4.6 Sexual behavior ....................................................................................................... 39 4.7. Factors influencing modern contraceptive use ....................................................... 41 4.7.1. Socio-demographic factors associated with use of modern contraceptive ...... 41 4.7.2. Other factors associated with use of modern contraceptives .......................... 43 4.7.3. Logistics regression of factors that influence use of modern contraceptive ... 44 University of Ghana http://ugspace.ug.edu.gh vi CHAPTER FIVE ............................................................................................................... 48 DISCUSSION .................................................................................................................... 48 5.1 Introduction ............................................................................................................. 48 5.2 Summary of findings ............................................................................................... 48 5.3 Explanation of findings and implications ............................................................... 51 5.4 Strengths and limitation of the study ...................................................................... 52 5.5 Conclusion .............................................................................................................. 52 CHAPTER SIX .................................................................................................................. 53 CONCLUSION AND RECOMMENDATIONS .............................................................. 53 6.1 Conclusion .............................................................................................................. 53 6.2 Recommendations ................................................................................................... 53 REFERENCES .................................................................................................................. 56 APPENDICES ................................................................................................................... 63 APPENDIX A: INFORMED CONSENT FORM ........................................................ 63 APPENDIX B: QUESTIONAIRE ................................................................................ 68 ETHICAL APPROVAL LETTER................................................................................ 76 University of Ghana http://ugspace.ug.edu.gh vii LIST OF TABLES Table 4.1: Socio-Demographic Characteristics of Respondents ...................................... 29 Table 4.2: Awareness and Knowledge of the use of modern contraceptives ................... 30 Table 4.3: Contraceptive use among respondents ............................................................ 33 Table 4.4: Socio-demographic characteristics of women who ever used modern contraceptive ................................................................................................... 35 Table 4.5: Socio-demographic characteristics against current contraceptive use ............ 38 Table 4.6: Sexual behavior of the respondents ................................................................. 40 Table 4.7: Socio-demographic factors associated with use of contraceptives .................. 42 Table 4.8: Other factors associated with use of modern contraceptives ........................... 43 Table 4.9: Logistics regression of factors that influence use of modern contraceptive ... 45 University of Ghana http://ugspace.ug.edu.gh viii LIST OF FIGURES Figure 1: Conceptual framework illustrating potential factors influencing modern contraceptive use among young refugee women in the Budumburam Refugee Camp ................................................................................................................ 17 Figure 2: Map of Budumburam area ................................................................................ 21 Figure 4.1: Knowledge of specific modern contraceptive methods ................................. 31 Figure 4.2: Source of information on contraceptives ....................................................... 32 Figure 4.3: Reasons for using modern contraceptives ...................................................... 34 Figure 4.4: Contraceptive method currently being use ..................................................... 34 University of Ghana http://ugspace.ug.edu.gh ix LIST OF ABBREVIATION ERCGHS………………………… Ethical Review Committee of the Ghana Health Service GDHS……………………………..Ghana Demographic Health Survey GHS……………………………… Ghana Health Service GHS……………………………….Ghana Health Service GMHS……………………………..Ghana Maternal Health Survey GSS……………………………… Ghana Statistical Service IUD………………………………..Intra Uterine Device LAM………………………………Lactational Amenorrhoea Method LWCR……………………………..Liberia Welfare Council for Refugee MCP……………………………… Modern Contraceptive Pills MDG………………………………Millennium Development Goal MOH………………………………Ministry OF Health NADMO…………………………..National Disaster Management Organization NGO……………………………….Non-Governmental Organization STDs………………………………Sexually Transmitted Disease UN……………………………….. United Nation UNHCR …………………………..United Nation High Commissioner for refugee WHO………………………………World Health Organization University of Ghana http://ugspace.ug.edu.gh x ABSTRACT Background: Despite high knowledge about modern contraceptives among young women, utilization levels are still low. Contraceptive prevalence is particular low among minority and under-served populations including refugees. Among young refugee women in the Budumburam refugee camp in Ghana, however, little research has been done to assess modern contraceptive use. The purpose of this study was to assess the use of modern contraceptives. Among young refugee women in the Budumburam refugee camp in Ghana. Methods: The study design was a cross sectional survey. A combination of cluster sampling and simple random sampling technique were used to select 242 young women between the ages of 15-24 years from the Budumburam refugee camp. Structured questionnaires were administered to these women to collect data. Data were analysed using STATA software version 13. Descriptive data analysis techniques (frequency, mean and standard deviation) and bivariate and logistic regression analyses were used to examine the use of modern contraceptives and factors associated with modern contraceptive use among young women in the refugee camp. Results: More than half of the respondents (64.5%) have ever heard about modern contraceptives. However, out of those who have ever had sex, only 33.88% had used modern contraceptive before. A number of factors were found to be influencing the contraceptive usage, including misconceptions about contraceptive use among young women and fear of side effects. Bivariate and logistic analyses showed that some socio- demographic and community level and service related factors such as age and country of birth were significantly associated with modern contraceptive usage. Conclusions: Findings from this study has provided vital baseline information about the factors that support or hinder the use of modern contraceptive among young women in the refugee camp. This information could potentially be used to effectively plan and deliver family planning and contraceptive services to young refugee women in the Budumburam refugee camp. University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE INTRODUCTION 1.0 Background A back-up method which women use to prevent unplanned pregnancy is modern contraceptive (WHO, 2015; Kolawole, Taiwo, Abubakar, Bashir, Zaggi & Hilary, 2015). In order to reduce induced abortion and prevent unplanned pregnancy modern contraceptive is the best strategy to use (Darteh, 2015). For instance, modern contraception pills (MCP) provide a safe and actual means of preventing at least 75% of unplanned pregnancies (Oriji & Omietimi, 2011). However, the percentage of women reported to have use of modern contraception is still very low and varies considerably across and within regions as well as across diverse populations (Westley, Kapp, Palermo & Bleck, 2013). For instance, in Asia, contraceptive use increased from 54% in 1990 to 57.4% in 2013 (Westley et al, 2013). However, contraceptive usage continues to be low in Sub-Saharan Africa, where modern contraceptive use increased marginally between 1990 and 2014 (Westley et al., 2013). Sahin and Shah (2009) suggest that the reasons for low modern contraceptives use include disapproval from partners, religious beliefs and fears that contraceptive use could cause abnormal bleeding, infertility, cancer, and pelvic pain. According to Ghana Statistical Service, (2011) about 35%of women currently married or in union reported using any method of contraception. There are however significant variations in modern contraceptive use among women in the reproductive age in Ghana. For example, contraceptive prevalence is highest in Greater Accra Region (44%) and Eastern – (43%) (Ghana Statistical Service, 2011). Contraceptive use is, however, lowest in Volta and Northern regions: only one in five married women (20%) reported using University of Ghana http://ugspace.ug.edu.gh 2 any method (Ghana Statistical Service, 2011).Young women are particularly far less likely to use contraception than older women - only 17% of married or women in union aged 15-19 currently use a method of contraception compared to 37% of women aged 20-24 years old and 38% of women aged 25-39 years (Ghana Statistical Service, 2011). This suggests the need to focus attention on young women more generally and young refugee women in particular. Indeed, while there are hardly any global or national level statistics on modern contraceptive prevalence among refugee populations, use of modern contraceptives has been reported to be lowest for vulnerable populations such as refugees (Waldman & Francoise, 2000). Worldwide, more than 26 million refugees, asylum-seekers and internally displaced persons are registered with the United Nations (UN) agencies, and millions more remain undocumented, and are often difficult to reach and lack security (WHO, 2015). Girls and women make up about 50% of refugees and internally displaced populations and are often at high risk of rape, unwanted pregnancies, unsafe delivery and sexually transmitted diseases (Waldman et al, 2000). Fleeing from war and settling in a refugee camp are extreme and unstable circumstances that place women at an increased risk for rape unwanted pregnancy, obstetric complications (Morrison, 2000). Indeed, it has been suggested that barriers to modern contraceptive use could be worse for refugee populations because resources that may have been available to young women in their own country, such as contraceptive supplies and reproductive health services, are often not available during refugee crisis (Waldman et al, 2000; Amalba, Mogre, Appiah, and University of Ghana http://ugspace.ug.edu.gh 3 Mumuni, 2014).Yet, the sexual and reproductive health needs of refugees are rarely addressed in policy and literature (Waldman et al, 2000). This study therefore aimed to contribute to understanding of modern contraceptive use among young women in Budumburam refugee camp in Ghana, focusing on whether or not young refugee women in the Budumburam refugee camp in Ghana use modern contraceptives; understanding young refugee women’s attitudes towards modern contraceptive use as well as the factors associated with use of modern contraceptive among young refugee women in the Budumburam refugee camp. 1.1 Problem Statement The use of modern contraceptives allows women to plan pregnancies, determine the spacing of pregnancies and achieve preferred number of children. Despite the importance of modern contraceptives in preventing unplanned pregnancy, women living in a refugee situation have been observed to have serious need for family planning services as they often face obstacles to practicing contraception (Amalba, Mogre, Appiah, & Mumuni, 2014). For instance, a study done in Ethiopia indicated that in spite of the increase rate of unplanned pregnancies among young women in refugee situations, the uptake of modern contraception to prevent such an occurrence amongst young women is disproportionately low and poorly understood (Nibabe and Mgutshini, 2014). Other previous studies have even found significant knowledge gaps in understanding and use of modern contraceptives among refugee populations. For instance, one study done in Senegal and Nigeria found that significant gaps in knowledge still exist in relation to young refugee women’s attitudes and knowledge of modern contraception use (Westley et al., 2013). University of Ghana http://ugspace.ug.edu.gh 4 While a number of studies have been conducted to examine contraceptive use practices and the determinants of contraceptive use among young women in non-refugee situations (Shoveller, Chabot, Soon & Levine 2007; Farhana, Karim, Ali & Arif 2009,Darroch, Sedeh, and Ball, 2011; Galvao, Diaz, Osis, Clark, 2015), few empirical studies have been undertaken to understand why contraceptive prevalence among young refugee women is low (Amalba, Mogre, Appiah, & Mumuni, 2014). In Ghana for example, the Budumburam refugee camp hosts more than 12,000 refugees. Yet, to the author’s knowledge, there are no studies that have examined modern contraceptives use among young women in the Budumburam refugee camp. This knowledge gap could potentially hinder effective planning and delivery of family planning support services as well as sexual and reproductive healthcare services to young women living in refugee situations such as the Budumburam refugee camp. This suggests the need for more research to understand modern contraceptive use among young refugee women and the factors affecting modern contraceptive use. For this reason, the present study aimed to contribute to filling this lacuna by examining modern contraceptives use among young refugee women in Budumburam refugee camp in Ghana. 1.2 Objectives The main objective of this study was to assess the use of modern contraceptive among young refugee women in the Budumburam refugee camp in Ghana. The specific objectives of the study were to: 1. Determine the prevalence of modern contraceptive use among young refugee women in the Budumburam refugee camp in Ghana use modern contraceptives. 2. Assess young refugee women attitudes towards modern contraceptive use. University of Ghana http://ugspace.ug.edu.gh 5 3. Determine the factors associated with use of modern contraceptive among young refugee women in the Budumburam refugee camp. 1.3 Research Questions 1. Do young refugee women in the Budumburam refugee camp in Ghana use modern contraceptive? 2. What are the attitudes of young refugee women perceive toward modern contraceptives use? 3. What factors influence the use of modern contraceptives among young refugee women in the Budumburam refugee camp in Ghana? 1.4 Justification of the Study As noted earlier, few studies have been conduct to assess contraceptives use among young women in refugee situations more generally and in the Budumburam refugee camp in Ghana more specifically. Therefore, the findings of this study could reveal hitherto unknown information related to the use of modern contraceptives among young refugee women. This information could potentially help to inform policy makers, international organizations, non-governmental organization, health experts and public health professionals to focus on the critical issues that will help to increase the current state of access to modern contraceptives and other sexual and reproductive health service for young refugee women. University of Ghana http://ugspace.ug.edu.gh 6 1.5 Conclusion This chapter gave a background to the study, stated the research problem and set out the research objectives and questions. The next chapter reviews relevant related literature in order to properly contextualize the present study. University of Ghana http://ugspace.ug.edu.gh 7 CHAPTER TWO LITERATURE REVIEW 2.0 Introduction This section reviews related literature on modern contraceptive use among young women in general and young refugee women in particular. The review is organized around clarifying key concepts and synthesizing literature and empirical related to the specific objectives of the study. The review particularly focuses on awareness and knowledge of modern contraceptives among young women, modern contraceptive use young women, and the factors influencing use of modern contraceptives. 2.1 Definition and types of contraceptive The Heritage Science Dictionary defines modern contraceptives as any device that prevents or tends to prevent conception. There are about 15 different types of contraceptives and most contraceptives work by preventing an egg from being released every month (hormones), preventing sperms from reaching the egg (barrier and Intra- uterine device methods), blocking the reproductive function in men or women (sterilization) and preventing a fertilized egg from implanting in the uterus (Biddlecom, 2015). However, Shriver (2013) has classified the different types of contraception as follows: barrier methods, hormonal methods, emergency contraception, intrauterine methods and sterilization. Shriver (2013) further describe each function as follows: 2.1.1 Barrier method Barrier methods prevent spermatozoa from coming in contact with the ovum. The advantages of barrier methods are: easy availability, protection against sexually transmitted diseases, cheap and safe (Clottey 2012). The barrier method comprises of the University of Ghana http://ugspace.ug.edu.gh 8 male and female condoms and diaphragms and cervical cap usually used with spermicide (Shriver, 2013). The male condom is a thin sheath that covers the penis to collect sperm and prevent it from entering the woman's body and also made of latex or polyurethane, which can reduce the risk of spreading sexually transmitted diseases (Shriver, 2013). Female condoms are thin, flexible plastic pouches in which a portion of the condom is inserted into a woman's vagina before intercourse to prevent sperm from entering the uterus and also reduces the risk of sexually transmitted diseases (Shriver, 2013). Diaphragm is a shallow, flexible cup made of latex or soft rubber that is inserted into the vagina before intercourse, blocking sperm from entering the uterus. Spermicidal cream or jelly often used with a diaphragm (Shriver, 2013). Cervical caps are similar to diaphragms, but smaller, more rigid, and less noticeable. The cervical cap is a thin silicone cup that is inserted into the vagina before intercourse to block sperm from entering the uterus (Shriver, 2013). Contraceptive sponges are soft, disposable, spermicide-filled foam sponges which is inserted into the vagina before intercourse. The sponge blocks sperm from entering the uterus and the spermicide also kills the sperm cells. Spermicide also destroys sperm and made up of foam, jelly, cream, suppository, and film (Shriver, 2013). 2.1.2 Hormonal Methods Shriver (2013) further talked about hormonal methods as birth control method that uses hormones to regulate or stop ovulation and prevent pregnancy. The following are some of the types: combined oral contraceptive pills which contain the different combinations of the synthetic estrogens and progestin and are given to interfere with ovulation. Progestin-only pills thicken cervical mucus, making it difficult for sperm to swim into the uterus or to enter the fallopian tube (Shriver 2013). Contraceptive patch is a thin, University of Ghana http://ugspace.ug.edu.gh 9 plastic patch that sticks to the skin and releases hormones through the skin into the bloodstream. The patch is placed on the lower abdomen, buttocks, outer arm, or upper body. Injectable birth control involves injection of a progestin, Depo-Provera given in the arm or buttocks once every 3 months (Shriver 2013). Another hormonal method is the vaginal ring, which is thin, flexible, and approximately 2 inches in diameter. It delivers a combination of a synthetic estrogen (ethinyl estradiol) and a progestin. The ring is inserted into the vagina, where it continually releases hormones for 3 weeks (Shriver 2013). The implantable rod is another hormonal method, and is a matchstick-sized, flexible, and plastic. A physician surgically inserts the rod under the skin of the woman's upper arm. The rods release a progestin and can remain implanted for up to 5 years. Emergency Contraceptive Pills are another type of hormonal pills, taken either as a single dose or two doses 12 hours apart, that are intended for use in the event of unprotected intercourse (Shriver 2013). Also included in the hormonal methods is the intrauterine method. This is a small, T- shaped device that is inserted into the uterus to prevent pregnancy. A copper intra uterine device releases a small amount of copper into the uterus, causing an inflammatory reaction that generally prevents sperm from reaching and fertilizing the egg. Copper intra uterine device may remain in the body for 12 years (Shriver 2013). A hormonal intra uterine device releases a progestin hormone into the uterus. The released hormone causes thickening of the cervical mucus, inhibits sperm from reaching or fertilizing the egg, University of Ghana http://ugspace.ug.edu.gh 10 thins the uterine lining, and also prevent the ovaries from releasing eggs. Hormonal intra uterine device can be used for up to 5 years (Shriver, 2013). 2.1.3 Sterilization Sterilization according to Shriver (2013) “is a permanent form of birth control that either prevents a woman from getting pregnant or prevents a man from releasing sperm. A health care provider performs the sterilization procedure, which usually involves surgery which is not reversible.” It is made up of the following: sterilization implant is a non- surgical method for permanently blocking the fallopian tubes of a woman (Shriver, 2013). Tubal ligation is a surgical procedure in which a doctor cuts, ties, or seals the fallopian tubes. This procedure blocks the path between the ovaries and the uterus. The sperm cannot reach the egg to fertilize it and the egg cannot reach the uterus (Shriver, 2013). Vasectomy is a surgical procedure that cuts, closes, or blocks the vas deferens. This procedure blocks the path between the testes and the urethra. The sperm cannot leave the testes and cannot reach the egg (Shriver, 2013). 2.1.4 Natural methods According to Clottey, (2012) natural methods of family planning are based on naturally observing occurring signs and symptoms of fertile and infertile phases of menstrual cycle, including abstention from intercourse during fertile phase. Major advantages of this method are the absence of physical side effects and freedom from dependence on medical personnel. The method requires some level of discipline and daily recordings, however. Natural methods include observation of cervical mucus, lactational amenorrhoea method, observation of body temperature, calendar or rhythm method and coitus interrupts or withdrawal (Clottey, 2012). University of Ghana http://ugspace.ug.edu.gh 11 2.1.5 Post-coital contraception Clottey (2012) further explained post-coital contraception as emergency contraception. Clottey (2012) also described the three methods of emergency contraception as combined oral emergency contraceptives, Progestin-only emergency contraceptives and insertion of a copper intra uterine device. 2.2 Awareness and Knowledge of modern contraceptive use among young women Use of modern contraception is prevalent across much of the developing world, but countries vary widely in total use and in the number and range of method choices available to potential users (Ross & Stover, 2013). However, the intra-uterine device is commonly available in the Middle East (Ross et al, 2013). A review of global access to modern contraceptives by Westley et al., (2013) reported in a study done in Senegal and Nigeria that significant gaps still exist in level of knowledge of modern contraception. A lot of young women are neither aware nor know of modern contraceptives methods. Even where they are aware and do know the different methods, they usually do not have access to them (Parker, 2005). Williamson, Parkes, Wight, Petticrew and Hart (2009) indicated that young women's use of modern contraceptive methods in five developing countries is limited by a range of factors, which centered on lack of knowledge and access. Inadequate knowledge may also stem from widespread assumptions and apathy (Appiah-agyekum & Kayi, 2013). Khan (2012) also found low contraceptive use among uneducated young women in Bangladesh, while (Nketiah-amponsah, Arthur, & Aaron, 2012) found similarly low levels of contraceptive use among young women in reproductive age in Ghana. University of Ghana http://ugspace.ug.edu.gh 12 Furthermore, another study in Ethiopia indicated that in spite of the high rate of unwanted pregnancies, the uptake of modern contraception to prevent such an occurrence amongst young women was disproportionately low and poorly understood (Nibabe et al, 2014). With regard to young women living in refugee situations, Parker (2005) found that there are a lot of young women who do not have knowledge or aware of modern contraceptives in refugee camps. A study done in a Kenyan refugee camp found that despite the availability of free condoms and other reproductive health care, about 70% of young refugee women had unplanned sex without using condoms (Kehinde, Mantue and Opeyemi, 2010). People living in refugee settlements have a serious need for modern contraceptive, yet face obstacles (economic, cultural and logistical) to practicing contraception (Halle-Ekane, Akwa, Sama, and Nsom, 2016). Improving modern contraceptive services in refugee settings not only safeguards to individual health and rights but also improves the quality of life for individual women, their husbands, and the children (Lule, Echorus and Mumuba, 2015). A study also done in Democratic Republic of Congo refugee camp showed that women in rural areas have reduced likelihood of using modern contraception than women living in urban areas (Ngianga-Bakwin , 2014).Watts and Mcmichael (2014), also stated that attitudes towards and use of contraception among young women in the refugee settings are influenced by parental sexual health literacy and attitudes, gender roles and culturally informed attitudes around motherhood. University of Ghana http://ugspace.ug.edu.gh 13 2.3 Attitudes towards modern contraceptives Unmet need is often portrayed as a problem of access, leaving the perception that women do not use contraceptives because they cannot find or afford them or they have to travel too far to get them (Tawiah, 2001; Darroch et al, 2011). While access is clearly an issue, women, especially young women, have many other reasons for not using family planning, including personal, cultural, or religious objections, health concerns, and lack of knowledge. For this reason, just making contraceptives available does not ensure that women will use them (Darroch et al, 2011). A study done by Tawiah (2001) for example shows that women’s attitude towards family planning and discussion of family planning have independent significant effects on use of contraception. A study done in British Columbia, Vancouver also indicated how young women misperceived modern contraception as an abortifacient and often mistakenly thought that it has long-term effects on health and fertility, stigmatizing messages from providers when they sought contraception and also low awareness of pharmacists’ prescriptive authority (Shoveller et al, 2007). 2.4 Factors influencing modern contraceptives use among young women Previous studies have suggested that several factors may influence contraceptive use and non-use especially among young women in general. For example, Kisaakye (2013) in a study done in Uganda indicated that the main factor that influence the use of contraceptive is the concern about health risks or side effects. Indeed, women reporting method-related reasons for not using a modern method account for about two-thirds of unmet need in Sub-Saharan Africa (67%) and South Central Asia (71%) and 79% of unmet need in South-East Asia (Darroch et al., 2011). Another study done by Williamson et al (2009) also indicated that young women's reputations and social status University of Ghana http://ugspace.ug.edu.gh 14 as well as social disapproval of premarital sex and pregnancy limit modern contraceptive use among young women. Some religious opinion also influences the use of contraceptives among young women. For instance, in Catholicism all forms of abortion and contraception are prohibited except for measures normally taken to save a mother (Amalba et al, 2014). Dissatisfaction among young women about the behavior of the healthcare providers portrays negative quality of care. Some health providers are openly rude to young women during provision of health services (Arube et al, 2008). Attitude of providers may be classified as sympathetic and supportive, less sympathetic and judgmental (Awusabo-Asare et al., 2008). While sympathetic providers create youth friendly images for their centres and thus promote patronage from adolescents, the less sympathetic and judgmental ones serve as barrier to the utilization of their services (Awusabo-Asare et al., 2008). Kisaakye, (2013) has also suggested that other factors that influence contraceptive use may include misperceptions about the safety and efficacy of long acting reversible contraceptives, inadequately trained providers and the relative complexity of providing long acting reversible contraceptives compared with short term contraceptive methods. However, several attempts have been made to revitalize the long-acting reversible contraceptives particularly the IUDs which are cost effective but these programmes have not yielded much success with utilization rates remaining very low especially in many developing countries (Blumenthal et al., 2012). Maya (2009) also found that health service factors which include the attitude of the providers, availability and affordability of contraceptives affect contraceptive use. Maya (2009) further explained that some providers stigmatize adolescent sexuality and are unwilling to acknowledge adolescents' experiences as contraceptive users. Others may even scold or treat adolescents who seek University of Ghana http://ugspace.ug.edu.gh 15 treatment from them harshly. Such attitudes undermine adolescents’ utilization of contraceptives (Wood et al., 2006). Other factors such as lack of privacy and confidentiality at the health facilities deter young women from patronizing their services (Maya, 2009). A study done Essaka (2015), also revealed that there were instances where health care providers were unable to provide services because resources and logistics were not available. In this regard, Awusabo-asare & Abane (2004) found that the main obstacle to contraceptive use among young people was the cost of the services. Finally, Essaka (2015) found that the consequences of breakdown in traditional institutions such as the system of clan elders, uncles, and aunts’ role in preparing young people for responsible adulthood also affect young women’s contraceptive use. Essaka (2015) therefore argues that parental or community acceptance of contraceptive services for young women cannot be ignored as it impacts access to family planning services as obtaining parental consent is a structural barrier that affects young women’s utilization of sexual and reproductive health services (Hock-Long, Brown, and Whitaker, 2003). Based on the various literature reviewed, literature on young refugee women’s use of modern contraceptives are lacking. 2.5 Conclusion In this chapter, relevant related literature was reviewed. The literature review suggests that despite the importance of contraceptives in preventing unplanned pregnancy, women living in a refugee situation may have a serious need for family planning services. At the same time, most previous studies have not considered the question of modern University of Ghana http://ugspace.ug.edu.gh 16 contraceptive use among young refugee women, especially in Ghana. This suggests the need for the present research project. 2.6 Conceptual framework While a number of studies have been conducted on modern contraceptive use among young women, no standard conceptual frameworks currently exist particularly in relation to the factors that may influence modern contraceptive use among young refugee women. Based on review of extant literature, however, a number of possible influencing factors have been identified. These have been used to develop a conceptual framework for the current research (see Figure 1). University of Ghana http://ugspace.ug.edu.gh 17 Figure 1: Conceptual framework illustrating potential factors influencing modern contraceptive use among young refugee women in the Budumburam Refugee Camp The conceptual framework consists of factors that influence the use of modern contraceptive methods, and attempts to explain how socio-demographic characteristics such as age, educational status, parity, and marital status, number of years living in the camp, religion, country of birth and person living with could affect use of modern contraceptives. Apart from socio-demographic influences, community and family level Individual factors Knowledge and awareness of contraceptive use Risky sexual behavior Community and family level factors  Attitude of community members towards modern contraceptives use  Partners consent  Perception and belief of contraceptive use  Cost of service  Peer influence  Approval from parents and other leaders of the family Socio-demographic (age, marital status, number of years living in the camp, religion, educational level, and country of birth, person staying with) Health facility related factors Counseling received about contraceptives Attitude of contraceptive providers Access to service and Skill of the providers Distance to acquisition contraceptive Use of modern contraceptives University of Ghana http://ugspace.ug.edu.gh 18 factors such as attitudes of community members towards modern contraceptive use, partner’s consent, approval from parents and other leaders of the family, perception and beliefs on contraceptive use, peer pressure could also influence utilization. Also, health facility or provider related factors such as cost of service, counseling received about contraceptives, distance to acquisition of service, attitudes of the contraceptive providers as well as access to the service could also affect modern contraception use. University of Ghana http://ugspace.ug.edu.gh 19 CHAPTER THREE METHODS 3.0 Introduction This chapter deals with the methods and techniques that were employed in this study. The chapter describes the study design, study area, the study population, sample size, sampling methods, data collection methods, quality control, data processing and analysis, and ethical considerations. 3.1 Study design The study design was a cross sectional survey. 3.2 Study area This study was conducted in the Budumburam refugee camp. The Budumburam refugee camp is located in the Gomoa east district of the central region of Ghana. It covers 44 kilometers (27 miles) west of Accra (United Nations High Commission for Refugees, 2008). It was opened by the United Nations High Commission for Refugees in 1990 (UNHCR, 2008). The camp is home to some 42,000 refugees although new refugees are received on a regular basis (UNHCR report, 2008). Most of the refugees are from Liberia who fled their country during the First Liberian Civil War (1989–1996) and the Second Liberian Civil War (1999–2003) (UNHCR report, 2008). In addition, refugees from Sierra Leone who also escaped from the ravages of their civil war (1991–2001) have also made the camp their home. Internally displaced Ghanaian refugees also live in the camp. For some years, the camp depended on the United Nation High Commission for Refugees for humanitarian assistance in the areas of providing food, healthcare and University of Ghana http://ugspace.ug.edu.gh 20 education. However, this aid came to a halt when the United Nation High Commission for Refugees began pulling out of the camp in April 2007 (UNHCR, 2008). Although the majority of the refugees engage in economic activities such as farming, trading, hairdressing, and catering in the camp and few works as labourers outside the camp (Dauda, 2012), poverty and ill-health is now a challenge because the refugees look after themselves (UNHCR, 2008). In terms of healthcare, the St Gregory Catholic hospital, also known as the Budumburam hospital, is the only hospital at the camp (Dauda, 2012). The hospital is currently operated by a Liberian doctor, who is also a refugee trained in Ghana. According to United Nation High Commission for Refugees report (2008), 2500 refugees were enrolled on Ghana’s National Health Insurance scheme. Malaria continue to be the highest cause of morbidity among the refugees. While HIV and AIDS services – which focus mainly on reducing stigma and encouraging free testing on the camp (UNHCR, 2008) are available, family planning and contraceptive services are limited in the camp. University of Ghana http://ugspace.ug.edu.gh 21 Figure 2: Map of Budumburam area 3.3 Study Population The target population of the study were young women between the ages of 15 and 24 years. 3.3.1 Inclusion criteria All females between the ages of 15 and 24 years living in the refugee camp at Budumburam in the central region were included in the study. 3.3.2 Exclusion criteria These are not part of the inclusion criteria to work with that is, all females not within the ages of 15 and 24 years and those who were within the age group but not resident in the Budumburam camp and those within the camp but who were not refugees were excluded. University of Ghana http://ugspace.ug.edu.gh 22 3.4 Sample size determination In order to determine an appropriate sample size for the study, Cochran (1977) statistical formula for estimating sample size for an infinite population was used. The formula is denoted as follows: : n= {z2p (1-p)}/d2 Where: n = minimum sample size required for the study; z = the desired confidence level (95% level of confidence or 1.96 in this particular study); d= 5%, expressed as decimal; p= expected proportion (i.e. the modern contraceptive prevalence rate in the camp is expected to be 18.4%). The minimum sample size required the study was calculated thus: n= {z2p (1-p)}/d2 n= {(1.96)2 x (0.17) x (0.83)/ (0.05)2 =230 A 5% non- response rate was expected. Therefore, the adjusted sample was recalculated as: 230 x 5/100= 11.4 Adding the 5% non- response rate (230 +11.4 = 241.4, approximate to 242), the sample size for the study was242. University of Ghana http://ugspace.ug.edu.gh 23 3.5 Sampling methods To obtain the sample size of 242 respondents, multi-stage sampling technique, where a combination of cluster and systematic random sampling techniques were used. Cluster sampling was particularly appropriate for the population of Budumburam camp because the camp is divided into clusters/zones. To do this, the names of the 12 zones within the Budumburam refugee camp were written on pieces of paper and put into a small container. The container was shaken and ten zones were randomly selected without replacement. This random sampling process gave all the zones an equal chance of being selected for the study. After the study zones had been selected, an equal number of respondents was selected from each of the ten zones. In each of the study zones, a bottle was spinned on the floor and where the apex of the bottle (that is, the mouth of the bottle) pointed was the starting point. From this point, every second house was selected by using systematic random sampling. Within the selected house, every young refugee woman aged 15 to 24 years were selected. In a situation where the selected house had no eligible respondent, or where the house had eligible respondents but they were unwilling to take part in the study, the next house was selected. This process continued until the required number of respondents were obtained in each of the study zones. 3.6 Data collection methods and instruments A structured questionnaire was designed and administered through face-to- face interview by the researcher. To avoid any misinterpretations of questions, the University of Ghana http://ugspace.ug.edu.gh 24 questionnaires were pre-tested in the remaining two zones after the ten zones had been selected using simple random sampling at the Budumburam refugee camp. This helped to evaluate respondents’ understanding of the questions. Questions that were found to be ambiguous were rephrased to ensure greater accuracy. Three research assistants were trained. The training involved discussion of the research objectives, the questions and the procedure for obtaining consent and/ or assent from respondents below 18 years age. The need to ensure privacy and confidentiality was also highlighted. During the training, each of them was made to administer some questionnaires and challenges observed were addressed. 3.7 Quality assurance The quality of the data was ensured based on the following measures. First, research assistants were employed and trained for the study. Second, data collected were checked to ensure accuracy and completeness. Third, errors detected were discussed with the research assistants and appropriate corrections were made. Fourth, errors or mistakes that were detected in the questionnaires which could not be corrected were excluded from the study. Finally, marking of the questionnaires were done to prevent double entry. 3.8. Data Entry and Processing Administered questionnaires were retrieved, cleaned, coded and entered into Microsoft Excel. The data was then exported to STATA Version 13 for analysis. University of Ghana http://ugspace.ug.edu.gh 25 3.9 Data Analysis 3.9.1 Variables Two main variables were considered in this study: outcome/dependent variable and independent variable. Outcome/dependent Variable The outcome variable for this study was Modern Contraceptive Use. Modern contraceptives here referred to the use of the following methods: female sterilization, male sterilization, intrauterine device (IUD), implants, injectable, the pill, male condoms and female condoms, and lactational amenorrhoea method (LAM). Independent Variables A number of independent variables were considered in the study. These were age, educational status, socio-economic status, knowledge about modern contraceptives, attitudes towards modern contraceptives, partner’s consent, counseling received about contraceptives, attitudes of the contraceptive providers and distance to acquisition of contraceptives. 3.9.2 Data Processing and Analysis Descriptive statistical analysis (frequencies, mean and standard deviation) were performed to describe modern contraceptive use, patterns, knowledge and attitudes among young refugee women in the Budumburam refugee camp. Bivariate and logistic regression analyses were also used to examine factors associated with modern contraceptive use among young women in the refugee camp. Confidence level was held University of Ghana http://ugspace.ug.edu.gh 26 at 95% and P<0.05 (at 5% level of significance) was considered as significant. Results were presented in tables, graphs and charts. 3.10 Ethical consideration Ethical approval was sought from the Ethics Review Committee of the Ghana Health Service in Accra. In addition, a letter of introduction from the School of Public Health, University of Ghana was obtained and sent to the Ghana Refugee Board at the camp to request permission to conduct the study in the camp. This letter was copied to the Office of the United Nation High Commissioner for Refugees (UNHCR) and the Liberian Refugee Welfare Council (LWFC) as well as to the opinion leaders of the camp (Zonal heads). In addition, young women who agreed to participate signed or thumb printed a written consent form after detailed explanations. The consent of parents or guardians was sought for respondents below 18 years. Such respondents were then required to accent to their parents/guardians’ consent. Participants had the option to discontinue their participation without any adverse consequence. Respondent in this study was entirely voluntary. Participants were assured of anonymity and confidentiality. Participants were assured of the fact that the work was purely for academic purposes and that no harm was intended. University of Ghana http://ugspace.ug.edu.gh 27 3.11 Conclusion This chapter presented the methods employed in the study. The chapter focused on the study design, study population, sampling, data collection and data analyses methods. In the next chapter, the results of the study are presented. University of Ghana http://ugspace.ug.edu.gh 28 CHAPTER FOUR RESULTS 4.1 Introduction This chapter presents the results generated from the data collected from the respondents. The results consist of the socio-demographic characteristics of the respondents, attitudes of respondents towards contraceptives, awareness and knowledge of contraceptives, and factors influencing the use of contraceptives. 4.2 Socio-demographic characteristics of the respondents A total of 242 respondents were planned for the study. Questionnaires were completed for all the 242 respondents, giving a response rate of 100%. Table 4.1 shows the background characteristics of the study respondents. Majority of the respondents (66.9%) were aged 15-19 years. The mean age of the respondent was 17.8 years (SD=+ 2.1). The majority of respondents (40.9%) were Ghanaians with several others from Liberia (29.3%), Sierra Leone (4.5%) and Ivory Coast (11.6%). Some 8.3% of the respondents have never been to school; 28.1% have been to primary school; 31% were in JHS, 23.6% were in SHS; 7.4% were in tertiary education; whiles 1.7% had other forms of education. Majority of the respondents (90.9% were unmarried whiles 9.1% were married. About 87% of the respondents were students. Majority (83.5%) of the respondents were Christians. Also, about 68% of the respondents were staying with their parents, 14.5% with their guardian, 6.2% lived with their partners, and 11.6% stayed alone. University of Ghana http://ugspace.ug.edu.gh 29 Table 4.1: Socio-Demographic Characteristics of Respondents Characteristic Frequency (n=242) Percent Age 15-19 162 66.9 20-24 80 33.1 Country of Birth Liberia 71 29.3 Sierra Leone 11 4.5 Ivory Coast 28 11.6 Ghana 99 40.9 Other 33 13.7 Level of Education None 20 8.3 Primary 68 28.1 JHS 75 31.0 Secondary 57 23.6 Tertiary 18 7.4 Other 4 1.7 Marital Status Married 22 9.1 Single 220 90.9 Occupation Student 210 86.8 Self – Employed 32 13.2 Religious Affiliation Christianity 203 83.9 Islamic 39 16.1 Person Respondent lives with Parents 164 67.8 Guardian 35 14.5 Partner 15 6.2 By myself 28 11.6 Highest level of education of mother None 76 31.4 Primary 45 18.6 JHS 69 28.5 Secondary 33 16.6 Tertiary 19 7.8 Highest level of education of father None 58 24.0 Primary 45 18.6 JHS 48 19.8 Secondary 53 21.9 Tertiary 38 15.7 Occupation of father Self-employed 154 63.6 Unemployed 54 22.3 Government worker 34 14.1 Occupation of mother Self-employed 164 68.1 Unemployed 63 26.1 Government worker 14 5.8 *JHS-Junior High School, SHS- Senior High School University of Ghana http://ugspace.ug.edu.gh 30 4.3 Awareness and knowledge of contraceptive methods Before examining the factors influencing modern contraceptive use among young women in the Budumburam Refugee Camp, respondents’ level of awareness and knowledge of modern contraceptive methods were assessed. Out of the 242 respondents, about 64.5% had heard about the term contraceptives (see table 4.2). Table 4.2: Awareness and Knowledge of the use of modern contraceptives Characteristic Frequency (n=242) Percent (%) Ever heard about modern contraceptives Yes 156 64.5 No 86 35.5 Knows specific place to get modern contraceptive* Hospital 27 11.2 Pharmacy 75 31.0 Health provider 2 0.8 Family planning/ PPAG Clinic 0 0.0 Friend/ Other 12 5.0 Don’t know 126 52.1 Thinks contraception is a woman’s business Yes 42 21.0 No 200 82.6 Thinks women who use contraceptives become promiscuous Yes 40 16.5 No 202 83.5 *Multiple responses allowed. Among respondents who have heard among contraception, the male condom (54.8%), pills (22.8%) and implants (19.2%) were mainly the contraceptives mentioned (see figure 4.1). Other methods identified were IUD (8.3%), injectable (11.8%), female condom (5.0%) and diaphragm (1.3%). Also, the majority (41.7%) of respondents heard of contraception through the television (41.7%), radio (27.6%) and health worker (11.5%). This is shown in figure 4.2. On specific places in the camp where they could get the University of Ghana http://ugspace.ug.edu.gh 31 contraceptive methods they had identified, pharmacy shop (31.0%), hospital (11.2%) and friends/others (5.0%) were the major places mentioned. Furthermore, 17.3% of the respondents thought that contraception is not a woman’s business while 82.7% indicated that it was a woman’s business and that men should not be concerned about it. Similarly, majority of the respondents (83.5%) thought that women who use contraception may become promiscuous. Figure 4.1: Knowledge of specific modern contraceptive methods 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Male Condom Pills Implants Injectables IUD Female Condom Diaphragm P er ce n ta ge s Modern Contraceptive Methods University of Ghana http://ugspace.ug.edu.gh 32 Figure 4.2: Source of information on contraceptives 4.4 Attitude toward modern contraceptive use Majority of the respondents who indicated that they have heard about modern contraceptives (52.6%) reported that they have used contraceptives before (see table 4.3). Out of the total 242 young women, only 33.9% said they had used a contraceptive before. In relation to reasons for using contraceptives, most of the respondents (70.7%) indicated that they use contraception to avoid teenage pregnancy and to prevent STIs (18.3%). This is shown in figure 4.3. Among the respondents who had used contraceptive before, most of them (64.6%) were also currently using modern contraceptives. The most common modern contraceptive methods currently being used were male condom (76.8%), pills (9.8%) and injectable (8.5%) as shown in figure 4.4. The main sources of these contraceptives were pharmacy/drug stores (72.0%). Most of the respondents reported to use contraceptive once in a while (59.8%) (See table 4.3). Also, most of the respondents said they have used modern contraceptives for a period less than one year (41.5%) and over a period of 1-2 years (31.7%). 27.60% 7.70% 11.50% 3.20% 6.40% 2.60% 4.50% 41.70% Radio Teacher Health Worker Family member Friends Partner Print media Television University of Ghana http://ugspace.ug.edu.gh 33 On who the respondents thought should use contraceptives, majority of the respondents (55.1%) said all sexually active persons should use contraceptives. Also, more than half (66.7%) of the respondents indicated that they could get any modern contraceptive by themselves. Table 4.3: Contraceptive use among respondents Statement Frequency Percent Used any modern contraceptive before(n=156) Yes 82 52.6 No 74 47.4 Currently Using Modern Contraceptives (n=82) Yes 53 64.6 No 29 35.4 Source of modern contraceptive in the camp (n=82) Hospital 7 8.5 Pharmacy 59 72.0 Health provider 4 4.9 Family planning 9 11.0 Other 3 3.7 Duration of usage of contraceptives (n=82) Less than one year 34 41.5 1-2 years 26 31.7 2-5 years 13 15.9 6-10 years 6 7.3 Other 3 3.7 Frequency of usage of method (n=82) Every time 33 40.2 Once a while 49 59.8 Opinion on who should use modern contraceptives Married couples only 48 30.8 All sexually active persons 86 55.1 Adults only 12 7.7 Don’t know 10 6.4 Able to get any modern contraceptive by self Yes 104 66.7 No 52 33.3 University of Ghana http://ugspace.ug.edu.gh 34 Figure 4.3: Reasons for using modern contraceptives Figure 4.4: Contraceptive method currently being use 4.5 Socio-demographic characteristics of women who ever used contraceptives Table 4.4 presents the socio-demographic characteristics of young women who had used contraceptives before. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Avoid pregnancy Prevent STIs Delay childbirth P e rc e n ta ge s Reasons 8.50% 1.20% 9.80% 2.40% 76.80% 1.20% Injectable Implants Pills Female condom Male condom Others University of Ghana http://ugspace.ug.edu.gh 35 Table 4.4: Socio-demographic characteristics of women who ever used modern contraceptive Characteristic Contraceptive Use, n (%) No Yes Age 15-19 129(80.6) 33(40.2) 20-24 31(19.4) 49(59.8) Country of birth Liberia 42(26.3) 29(35.4) Sierra Leone 4(2.5) 7(8.5) Ivory Coast 15(9.4) 13(15.9) Ghana 70(43.8) 29(35.4) Other 29(18.1) 4(4.9) Educational Status None 11(6.9) 9(11.0) Primary 50(31.3) 18(22.0) JHS 62(38.8) 13(15.9) Secondary 31(19.4) 26(31.7) Tertiary 2(1.3) 16(19.5) Other 4(2.5) 0(0.0) Religion Christianity 137(85.6) 66(80.5) Islamic 23(14.4) 16(19.5) Marital Status Married 11(6.9) 11(13.4) Single 149(93.1) 71(86.6) Person Living With Parents 121(75.6) 43(52.4) Guardian 23(14.4) 12(14.6) Partner 8(5.0) 7(8.5) By myself 8(5.0) 20(24.4) Educational Status of mothers None 48(30.0) 28(34.2) Primary 27(16.9) 18(22.0) JHS 49(30.6) 20(24.4) SHS 25(15.6) 8(9.8) Tertiary 11(6.9) 8(9.8) Educational Status of father None 37(23.1) 21(25.6) Primary 30(18.8) 15(18.3) JHS 36(22.5) 12(14.6) SHS 35(21.9) 18(22.0) Tertiary 22(13.8) 16(19.5) University of Ghana http://ugspace.ug.edu.gh 36 Occupation of father Self-employed 101(63.1) 53(64.6) Unemployed 37(23.1) 17(20.7) Government worker 22(13.8) 12(14.6) Occupation of mother Self-employed 109(68.1) 55(67.9) Unemployed 44(27.5) 19(23.5) Government worker 7(4.4) 7(8.6) The results showed that most of the respondents (59.8%) who had used contraceptive before were aged 20-24 and were Ghanaians (35.4%). Furthermore, majority of the young women had secondary education (31.7%), were not married (86.6%) and Christians (80.5%). More than half of them stayed with their parents (52.4%) and most of them had mothers (34.2%) and fathers (25.6%) with no formal education. Moreover, most of these young women had fathers (64.6%) and mothers (67.9%) who were self- employed (see table 4.4) 4.5 Socio-demographic characteristics of women who currently use contraceptives Table 4.5 also presents information on the socio-demographic characteristics of young women who currently use contraceptives. Most of the young women who currently use contraceptive were aged 20-24 years and were Ghanaians (35.9%), whereas most current contraceptive non-users were among Liberians (41.4%). Most of the current contraceptive users had secondary education (35.9%) while most of the current non-users had primary education (37.9%). More than half of the current contraceptive users were Christians (77.4%), single women (84.9%), and most of them stayed with their parents (49.1%). On the educational status of their parents, mothers of most of the current users had no formal education (34.0%) likewise their fathers (26.4%). However, fathers of most of the current non-users had primary education (31.0%) whereas mothers of most current non-users had primary (34.5%) or no education (34.5%). In relation to the University of Ghana http://ugspace.ug.edu.gh 37 occupation of the young women, the parents of most of the current contraceptive users and non-users were self-employed (see table 4.5). University of Ghana http://ugspace.ug.edu.gh 38 Table 4.5: Socio-demographic characteristics against current contraceptive use Characteristic Current contraceptive Use, n (%) No Yes Age 15-19 14(48.3) 19(35.8) 20-24 15(51.7) 34(64.2) Country of birth Liberia 12(41.4) 17(32.1) Sierra Leone 1(3.5) 6(11.2) Ivory Coast 4(13.8) 9(17.0) Ghana 10(34.5) 19(35.9) Other 2(6.9) 2(3.8) Educational Status None 3(10.3) 6(11.3) Primary 11(37.9) 7(13.2) JHS 6(20.7) 7(13.2) Secondary 7(24.1) 19(35.9) Tertiary 2(6.9) 14(26.4) Other Religion Christianity 25(86.2) 41(77.4) Islamic 4(13.8) 12(22.6) Marital Status Married 3(10.3) 8(15.1) Single 26(89.7) 45(84.9) Person Living With Parents 17(58.6) 26(49.1) Guardian 3(10.3) 9(17.0) Partner 2(6.9) 5(9.4) By myself 7(24.1) 13(24.5) Educational Status of mothers None 10(34.5) 18(34.0) Primary 10(34.5) 8(15.1) JHS 6(20.7) 14(26.4) SHS 2(6.9) 6(11.3) Tertiary 1(3.5) 7(13.2) Educational Status of father None 7(24.1) 14(26.4) Primary 9(31.0) 6(11.3) JHS 4(13.8) 8(15.1) SHS 5(17.2) 13(24.5) Tertiary 4(13.8) 12(22.6) Occupation of father Self-employed 20(69.0) 33(62.3) Unemployed 6(20.7) 11(20.8) Government worker 3(10.3) 9(17.0) Occupation of mother Self-employed 21(72.4) 34(65.4) Unemployed 6(20.7) 13(25.0) Government worker 2(6.9) 5(9.6) University of Ghana http://ugspace.ug.edu.gh 39 4.6 Sexual behavior Questions were also asked to determine sexual behaviors among the study respondents. The results are presented in table 4.6. Some 51.2% of the respondents reported to have had sex before, and among them about 60% engaged in sex at ages 15-19. Furthermore, majority of the respondents (62.0%) indicated that they did not currently have sexual partners. On past sexual behaviors, most of the respondents (90.5%) indicated they had never engaged in sex while drunk, but only 9.5% indicated they had involved in such an act before. Among those who had engaged in sex while drunk, 43.5% of them reported to have used a contraceptive. Furthermore, most of the respondents (85.5%) indicated they had never been pressurized to have unprotected sex. However, among those who indicated to have been pressurized to have unprotected sex, most of them had been pressured by their friends (62.9%) and partners (31.4%). With regard to sex education, more than half of the respondents (59.1%) were of the view that sex education had influence on modern contraceptive use. Moreover, majority of the respondents indicated to have received sex education in school (70.3%) and in the house (51.7%). However, only 25.6% of the respondents reported to have received sex education in the church and/or mosque, while majority of them (67.8%) stated otherwise. University of Ghana http://ugspace.ug.edu.gh 40 Table 4.6: Sexual behavior of the respondents Statement Frequency Percent Ever had sex before Yes 124 51.2 No 118 48.8 Age at first sex 15-19 74 59.7 20-24 50 40.3 Currently have sexual partner Yes 92 38.0 No 150 62.0 Ever had sexual intercourse while drunk Yes 23 9.5 No 219 90.5 Use contraceptives while drunk Yes 10 4.13 No 13 5.37 Number of sexual partners ever had 1-3 83 34.3 4-6 16 6.6 7-9 1 0.4 10-12 1 0.4 None 141 58.3 Number of sexual partners in the last 12 months 1-3 83 34.3 4-6 16 6.6 None 143 59.1 Pressured to have unprotected sexual intercourse Yes 35 14.5 No 207 85.5 Source of Pressure Friends 22 62.8 Relatives 2 5.7 Partner 11 31.4 Had sex education in school Yes 170 70.25 No 52 21.49 Not Applicable 20 8.3 Had sex education in house Yes 125 51.65 No 117 48.35 Any sex education in church/mosque Yes 62 25.62 No 164 67.77 Not Applicable 16 6.61 University of Ghana http://ugspace.ug.edu.gh 41 4.7. Factors influencing modern contraceptive use 4.7.1. Socio-demographic factors associated with use of modern contraceptive Table 4.7 presents the results of a bivariate analysis to explore the association between various socio-demographic variables and use of modern contraceptives. Age was significantly associated with use of modern contraceptive among young women (p<0.0001). Majority of the respondents aged 15-19 years (79.6%) did not use modern contraceptives whereas most of the respondents aged 20-24 years (61.2%) used contraceptives. Country of birth of the respondent was also found to be related to use of contraceptives (p<0.003). Most of the Ghanaians (70.7%) reported not to be using contraceptives as compared to 29.3% of them who use contraceptives. Also, as much as 59.1% of the Liberians did not use contraceptives compared to 40.9% of them who use contraceptives. The respondent educational level was also found to be related to the use of modern contraceptives (p<0.0001). More than half of the respondents who had primary education (73.5%) did not use contraceptives compared to 11.1% of the respondents who had attained tertiary education. Who a respondent lived with was found to be related to contraceptive use (p<0.0001). More than half (62.4%) of the respondents who stayed with their parents did not use contraceptives compared 71.4% who stayed by themselves and used contraceptives. Religion, and educational status of both mother and father were however not significantly associated with modern contraceptive use. University of Ghana http://ugspace.ug.edu.gh 42 Table 4.7: Socio-demographic factors associated with use of contraceptives Characteristic Contraceptive Use, n (%) 𝑿𝟐 P-Value No Yes Age 15-19 129(79.6) 33(20.4) 39.9485 0.0001* 20-24 31(38.8) 49(61.2) Country of birth Liberia 42(59.1) 29(40.9) Sierra Leone 4(36.3) 7(63.7) Ivory Coast 15(53.6) 13(46.4) 15.7569 0.003* Ghana 70(70.7) 29(29.3) Other 29(87.9) 4(12.1) Educational Status None 11(55) 9(45) Primary 50(73.5) 18(26.5) JHS 62(82.7) 13(17.3) 41.8018 0.0001* Secondary 31(54.4) 26(45.6) Tertiary 2(11.1) 16(88.9) Other 4(100) 0(0) Religion Christianity 137(67.5) 66(32.5) 1.0584 0.304 Islamic 23(59) 16(41) Marital Status Married 11(50) 11(50) 2.8055 0.094 Single 149(67.7) 71(32.3) Person Living With Parents 121(62.4) 43(37.6) Guardian 23(65.7) 12(34.3) 23.0146 0.0001* Partner 8(53.3) 7(46.7) Self 8(28.6) 20(71.4) Educational Status of mother None 48(63.1) 28(36.9) Primary 26(57.8) 19(42.2) JHS 50(72.5) 19(27.5) 4.8770 0.300 SHS 25(75.8) 8(24.2) Tertiary 11(57.9) 8(42.1) Educational Status of father None 37(63.8) 21(36.2) Primary 30(66.7) 15(33.3) 2.9834 0.561 JHS 36(75) 12(25) SHS 35(66) 18(34) Tertiary 22(57.9) 16(42.1) *p<0.05; X2= Chi-square statistics University of Ghana http://ugspace.ug.edu.gh 43 4.7.2. Other factors associated with use of modern contraceptives Table 4.8 also provides information on further bivariate analysis of other factors that are associated with use of modern contraceptives. The results indicate significant association between respondents who currently have sexual partner and the use of contraceptive (𝑝 < 0.001). Table 4.8: Other factors associated with use of modern contraceptives Characteristic Contraceptive Use, n (%) 𝑿𝟐 P- Value No Yes Currently have sexual Partner Yes 24(26.1) 68(73.9) No 136(90.7) 14(9.3) 106.1580 0.0001* Knows a place in the Community to get Contraceptive Yes 33(55) 27(45) No 127(69.8) 55(30.2) 4.4001 0.036* Thinks one unprotected sex can result in pregnancy Yes 55(49.5) 56(50.5) No 12(50) 12(50) 37.0440 0.001* Don’t Know 93(86.9) 14(13.1) Thinks modern contraceptive can offer 100% protection against pregnancy Yes 39(41.9) 54(58.1) No 33(68.8) 15(31.2) 44.3269 0.001* Don’t Know 88(87.1) 13(12.9) Thinks contraceptive is women’s business Yes 72(92.3) 6(7.7) No 21(58.3) 15(41.7) 35.6951 0.000* Don’t Know 67(52.3) 61(47.7) Thinks women using modern contraceptive may become promiscuous Yes 70(90.3) 6(6.7) No 13(37.1) 22(62.9) 40.6629 0.001* Don’t know 75(58.1) 54(41.9) Had sex Education in school Yes 115(67.7) 55(32.3) No 34(65.4) 18(34.6) 1.2934 0.524 Don’t know 11(55) 9(45) Had sex education in house Yes 91(72.8) 34(27.2) No 69(59) 48(41) 3.1564 0.053 *p<0.05; X2= Chi-square statistics University of Ghana http://ugspace.ug.edu.gh 44 Most of those who currently have a sexual partner (73.9%) used contraceptives whereas most of the respondents who had no sexual partners (90.7%) did not use contraceptives. Knowing a place in the community to get contraceptive had a significant relationship with use of contraceptives ( 𝑝 < 0.036). Most of the respondents (69.8%) who did not know a place in the community to get contraceptives did not use contraceptives. Knowledge that one unprotected sex can result in pregnancy had a relationship with use of contraceptive (𝑝 < 0.0001). Furthermore, belief that contraceptive was women’s business was significantly associated with contraceptive use. Most of the respondents (92.3%) who believed that contraceptive was women’s business did not use contraceptive ( 𝑝 < 0.0001). Also, most of the respondents (90.3%) who said women who use modern contraceptive may become promiscuous never used contraceptive ( 𝑝 < 0.001). There was however no significant association found between contraceptive use and the following variables: having sex education in school (p<0.524), and having sex education in house (p<0.053). 4.7.3. Logistics regression of factors that influence use of modern contraceptive A total of 18 variables were examined in the bivariate analysis. Out of this number, 11 showed significant association with contraceptive use. A logistic regression analysis was therefore performed on these 11 variables. Table 4.9 shows the results of the logistic regression analysis. Young women between the ages of 20-24 years had an increased odd of using modern contraceptives as compared to 15-19 years (OR: 6.17; 95%CI= 2.55- 9.04). On the country of birth, young women from Ghana were at reduced odds of not using of modern contraceptives compared to young women from other countries (OR: O.6; 95%CI=0.31-1.13). University of Ghana http://ugspace.ug.edu.gh 45 Table 4.9: Logistics regression of factors that influence use of modern contraceptive Characteristics Contraceptive use, n (%) Unadjusted 95% CI Adjusted OR (95%CI) No Yes Age** 15-19(ref) 129(79.6) 33(20.4) 1 1 20-24* 31(38.8) 49(61.2) 6.17(3.42-11.15) 4.80(2.55-9.04) Country of birth** Liberia(ref) 42(59.1) 29(40.9) 1 1 Sierra Leone 4(36.3) 7(63.7) 2.53(0.67-9.45) 3.05(0.69-13.49) Ivory Coast 15(53.6) 13(46.4) 1.25(0.52-3.02) 0.87(0.31-2.41) Ghana 70(70.7) 29(29.3) 0.6(0.31-1.13) 0.68(0.33-1.39) Other* 29(87.9) 4(12.1) 0.19(0.43-1.1) 0.23(0.06-0.81) Educational Status** None(ref) 11(55) 9(45) 1 1 Primary 50(73.5) 18(26.5) 0.44(0.15-1.23) 0.73(0.22-2.42) JHS 62(82.7) 13(17.3) 0.25(0.08-0.74) 0.42(0.12-1.43) Secondary 31(54.4) 26(45.6) 1.02(0.36-2.85) 0.83(0.27-2.49) Tertiary 2(11.1) 16(88.9) 9.70(1.76-54.20) 5.75(0.94-34.99) Person Living With*** Parents(ref) 121(62.4) 43(37.6) 1 1 Guardian 23(65.7) 12(34.3) 1.46(0.67-3.20) 1.12(0.47-2.62) Partner 8(53.3) 7(46.7) 2.46(0.84-7.19) 1.99(0.59-6.69) Self* 8(28.6) 20(71.4) 7.03(2.88-14.14) 3.77(1.38-10.33) Currently have sexual Partner** Yes(ref) 24(26.1) 68(73.9) 1 No* 136(90.7) 14(9.3) 0.03(0.017-0.07) 0.03(0.017-0.08) Knows a place in the Community to get Contraceptive** Yes(ref) 33(55) 27(45) 1 1 No 127(69.8) 55(30.2) 0.52(0.29-0.96) 0.62(0.30-1.27) Thinks one unprotected sex can result in pregnancy** Yes(ref) 55(49.5) 56(50.5) 1 1 No 12(50) 12(50) 0.98(0.40-2.37) 0.50(0.42-3.12) Don’t Know* 93(86.9) 14(13.1) 0.14(0.07-0.29) 0.19(0.09-0.39) Thinks modern contraceptive can offer 100% protection against pregnancy** Yes(ref) 39(41.9) 54(58.1) 1 1 No* 33(68.8) 15(31.2) 0.32(0.15-0.68) 0.20(0.08-0.48) Don’t Know* 88(87.1) 13(12.9) 0.10(0.05-0.21) 012(0.05-0.27) University of Ghana http://ugspace.ug.edu.gh 46 Thinks contraceptive is women’s business** Yes(ref) 72(92.3) 6(7.7) 1 1 No* 21(58.3) 15(41.7) 8.57(2.95-24.84) 6.54(2.13-20.1) Don’t Know* 67(52.3) 61(47.7) 10.92(4.43-26.9) 8.38(3.20-21.9) Thinks women using modern contraceptive may become promiscuous*** Yes(ref) 70(90.3) 6(6.7) 1 1 No* 13(37.1) 22(62.9) 20.3(6.9-59.7) 14.7(4.6-47.2) Don’t know* 75(58.1) 54(41.9) 8.63(3.5-21.3) 6.77(2.16-17.5) CI=Confidence Interval; (The * has p value < 0.05). Also, the number of sexual partners that the respondent had in the last 12 months was also found to be associated use of contraceptives. Young women who have had 4-6 sexual partners in the last 12 months had 3% odds of contraceptives use compared to those who have had 1-3 sexual partners (OR: 0.03; 95% CI=0.00-0.17). The odds of contraceptive use among respondents who did not know of a place in the community to get contraceptives was (OR=0.52; 95%CI=0.29-0.96) compared to those who knew of a place in the community to get contraceptives. There were also decreased odds of contraceptive use among young women who indicated that one unprotected sex could not result in pregnancy (OR=0.98; 95%CI=0.40-2.37) compared to young women who answered in the affirmative. Moreover, respondents who thought modern contraceptives could not offer 100% protection from pregnancy were found to have reduced odds of contraceptives (OR=0.32; 95%CI=0.15-0.68) compared to those who answered affirmative. Young women who did not think that contraceptive was women’s business (OR=10.92; 95%CI=4.43-26.9) and women using modern contraceptive may become promiscuous (OR=20.3; 95% CI=6.9-59.7) were found to have increased odds of contraceptive use compared to those who gave positive answers. University of Ghana http://ugspace.ug.edu.gh 47 4.8 Conclusion This chapter presented the results of the study. The results revealed that most of the young women had knowledge of modern contraceptives. However, contraceptive usage was still low. A number of socio-demographic and community and health facility level factors were found to be significantly associated with use of modern contraceptives. In the next chapter, these findings are discussed in detail. University of Ghana http://ugspace.ug.edu.gh 48 CHAPTER FIVE DISCUSSION 5.1 Introduction This chapter discusses the main findings from the study. The discussion is organized into summary of findings, consistency with previous research, explanation of findings and implication, strength and limitations, and conclusion. 5.2 Summary of findings This study sought to assess the use of modern contraceptive among young refugee women in the Budumburam refugee camp in Ghana. Results presented in the previous chapter suggested that awareness and knowledge of modern contraceptive among the study respondents was high: more than half of the respondents (64.5%) have heard of modern contraceptives and their major source of information were from radio and television. The major common modern contraceptive methods mentioned by the respondents were male condoms (76.8%), pills (9.8%) and implants (8.5%). The young women at the camp mentioned that they could get the contraceptive methods mentioned mostly from pharmacy shop and hospitals. The majority of the respondents however thought that contraceptive usage is a woman’s business and that women become promiscuous whiles using modern contraceptives. In addition, the study found that the majority of the respondents who indicated they have heard of modern contraceptives have never used contraceptive before showing that less than half of the respondents have used contraceptive before. The most common contraceptive method used was male condom and it was indicated that the respondent use contraceptive mostly to prevent pregnancy. University of Ghana http://ugspace.ug.edu.gh 49 Furthermore, the sexual behaviors of the young women who took part in the study were explored. Findings indicated that the young women in the refugee camp practiced risky sexual behavior as evidence by multiple sexual partners. Majority of the respondents indicated that they have never had sex while drunk as well as being pressurized to have unprotected sex. With regard to the few respondents who were pressurized to have unprotected sex, the pressure came mostly from friends and partners. Most of the respondents indicated that sex education influenced modern contraceptive usage. In addition, there were factors that influenced modern contraceptive use among young women in the camp. These factors included age, country of birth and educational level of the respondents. Having a current sexual partner, knowing a place in the community to get contraceptives as well as the belief that contraceptive was women’s business were also associated with modern contraceptive use. Taken together, the findings of the study showed that although awareness and knowledge of contraceptives use were high, modern contraceptive usage among young women in the refugee camp was low. 5.3 Consistency with previous research The study found high awareness and knowledge about modern contraceptives among young women in the Budumburam refugee camp in Ghana. However, awareness and knowledge levels were lower than the levels reported in a study in central Tanzania where 98.8% of the respondents indicated to be aware of the contraceptive methods (Lwelamira et al, 2012). Also, the observed contraceptive prevalence rate in this study was low as compared with 58.5% that was reported by Mbonile et al (2014) in a study University of Ghana http://ugspace.ug.edu.gh 50 done in Tanzania and 46% reported by Nsugaba et al, (2016).The study found that more than half of the respondents have heard of modern contraceptives and their major source of information were from radio and television. The major common modern contraceptive methods mentioned by the respondents were male condoms, pills and implants. This is similar to what has been found in other studies in Ghana (Motta-Martins, 2006; Maya, 2009; Enuameh, 2015). This is also consistent with another study done by Clottey, (2012), which reported that 84.5% of the respondents have heard of contraceptive with condoms and pills being the most widely known methods as well as contraceptive usage with radio and television being the main source of information. The majority of the respondents thought that contraceptive usage was a woman’s business and that women become promiscuous whiles using modern contraceptives. This finding is similar to a study done by Awusabo-Asare et al (2006) which stated that the use of contraceptive was a women’s business and that contraceptive use could lead in promiscuity among young women. The current study also found that the majority of respondents indicated that they have heard of modern contraceptives but have never used contraceptive before which shows that less than half of the respondents have used contraceptive before. The most common contraceptive method used was male condom and it was indicated that the respondent use contraceptive mostly to prevent pregnancy as the main reason for using contraceptive. This corroborates similar studies in Kenya and in Ghana, in which less than 20% of sexually active adolescents in Kenya used contraceptives and less than 15% in Ghana use modern contraceptives (USAID, 2011). Finally, the current study found factors that influenced modern contraceptive use among young women in the camp to include having sexual partners, knowing a place in the University of Ghana http://ugspace.ug.edu.gh 51 community to get contraceptives as well as the belief that contraceptive was women’s business. Similar findings have been reported by Atiglo (2013) and Mbonile et al (2014). 5.3 Explanation of findings and implications The study findings corroborated that young women generally reported high level of knowledge of modern contraceptive methods but low contraceptive use. Young women between the ages of 20-24 years were at the increased odds of using modern contraceptive compared to 15-19 years group. This mean that older young women are likely to use modern contraceptives because of the level of maturity than the young ones. This is because the matured young women are more enlightened and with high increase of awareness and knowledge than the young ones. The level of education of the young women were found to be significant predictor of modern contraceptive usage. As young women with formal education have a higher chances of using modern contraceptive than those without education. This is because young women with educational attainment have more knowledge on the various methods of modern contraceptives with it benefits than their counter part. Furthermore, the study findings evidenced an association of who the respondent living with had an influence on modern contraceptive usage. Majority of the respondent who stayed with their parents did not use contraceptives compared to those who stayed alone or with partners and used contraceptives. There were also no significant relationship between parents’ educational status and religion with modern contraceptive use. University of Ghana http://ugspace.ug.edu.gh 52 5.4 Strengths and limitation of the study This study has provided important standard information regarding the pattern of contraceptive use among young women in Budumburam refugee camp. In addition, the findings provide insight for programme managers on how and to whom educational message on contraception should be targeted. This notwithstanding, the study has some limitations. First, since this was a cross-sectional study design, it was not possible to assess cause and effect relationship. Related to this, it was not possible to explore the barriers to contraceptive use in detail. Future research could employ qualitative study designs to explore the barriers to utilization of contraceptive in this population. Secondly, the study was carried out in the Budumburam refugee camp in Gomoa East which is just a community in Gomoa East and might not represent the whole young women in Gomoa East district, thus results may not be generalizable to other district of Gomoa East. Finally, due to the nature of the study which involved sensitivity matters and self-reporting, information bias could be introduced which may have affected reliability of the results. 5.5 Conclusion This chapter discussed the results of this study. The discussion in the chapter suggested that despite the high level of awareness and knowledge about contraceptives among young refugee women, actual usage is still very low. A number of socio-demographic and community level factors were found to be associated with non-use of modern contraceptives. The findings and the discussions in the chapter highlight the need for remedial interventions to improve contraception use among the study population. The next chapter proposes specific recommendations to help redress the situation. University of Ghana http://ugspace.ug.edu.gh 53 CHAPTER SIX CONCLUSION AND RECOMMENDATIONS 6.1 Conclusion This study was conducted in the Budumburam refugee camp in Gomoa East to determine modern contraceptive use among young refugee women and the factors influencing contraceptive use. The study sampled young women between the ages of 15-24 years residing within the twelve zones in the camp. A total of 242 young women were interviewed using structured questionnaires. Contraceptive prevalence rate among young women within the Camp is low. Based on these findings, this study concludes that awareness and knowledge of modern contraceptives does not necessarily lead to utilization. Therefore, measures to improve contraceptive use among young women in the camp are urgently needed. 6.2 Recommendations Based on the findings from this study, the following recommendations are made. 1. First, the results showed that some of the young women were not aware of some of the methods of modern contraceptives. Healthcare providers from the Ghana Health Service should educate young women on the various methods of modern contraceptives so as help dispel misconceptions about site effects and help young women decide on which options they want. Providers should particularly take advantage of social gatherings of young women to deliver modern contraceptive educational messages. Providers should have a friendly approach to young women who seek help on contraceptive usage. 2. Second, most of the young women indicated that sex education is not taught in schools. Therefore, it is recommended that the Ministry of education and Ghana University of Ghana http://ugspace.ug.edu.gh 54 education Service should work with management of the camp to add sex education to school curriculum in the camp to help increase awareness and knowledge on sexual and reproductive health matters among young women. 3. Third, majority of the young women reported that they acquired knowledge on modern contraceptives mainly through radio and Television. The National Commission on Civic Education in partnership with the National Media Commission, Information Services Department and Ghana Health Services should ensure frequent dissemination of correct information on sexual and reproductive health through the radio and television as these are major sources of contraceptive knowledge among young women. It is therefore important to promote benefits and dispel barriers to contraceptive use among young women through the media. 4. Fourth, there are no adolescent corners and centres at the camp to give counselling and accurate information as well as reproductive health services to the young women. The Ministry of Health should establish more adolescent sexual and reproductive health services and centres to make it friendly by providing counselling services and screening programmes, adequate logistics on modern contraceptives within the zones. 5. Fifth, majority of the young women are unemployed and in schools. Therefore, financial barriers that restrict contraceptive access and use must be removed. As part of the National Health Insurance Scheme, modern contraceptive methods should be greatly subsidized or provided freely to increase contraceptive usage in the camp. 6. Finally, additional research is needed to understand the barriers to contraceptive use in particular type of contraceptives used and reasons for not utilizing services University of Ghana http://ugspace.ug.edu.gh 55 provided in health facility within the camp. Future studies also need to use different recruitment and data collection approaches to enhance high participation rate enhance the breadth and depth of the findings. University of Ghana http://ugspace.ug.edu.gh 56 REFERENCES Amalba, A., Mogre, V., Appiah, M. N. A., & Mumuni, W. A. (2014). Awareness , use and associated factors of emergency contraceptive pills among women of reproductive age ( 15-49 years ) in Tamale , Ghana, 14(1), 1–6. http://doi.org/10.1186/1472-6874-14-114 Appiah-agyekum, N. N., & Kayi, E. A. (2013). Students ’ Perceptions of Contraceptives in University of Ghana, 7(1), 39–44. http://ugspace.edu.gh Arube-wani, J., Jitta, J., & Ssengooba, L. M. (2008) . 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Sahin, H.A, &Shah, H.G, (2009) Reasons for not using family planning methods in Eastern Turkey.European Journal of Contraception and Reproductive health care.doi.10.1080/ejc20/8/1.journal:peer review integrity. date accessed 11/10/15. Shoveller, J., Chabot, C., Soon, J. A.,& Levine, M. (2007), Identifying Barriers to Emergency Contraception Use among Young Women from Various Sociocultural Groups in British Columbia, Canada. Perspectives on Sexual and Reproductive Health, 39: 13–20. doi: 10.1363/3901307 date accessed 09/10/15 Shriver, E.K.(2013) national institute of child health and human development.health research throught life span.http://www.nichdinid.govt/healthtopic/contraception. date accessed 03/11/15 Tawiah, E. O. (2001). Science : factors affecting contraceptive use in ghana factors affecting contraceptive use, (1997), 141–149. University of Ghana http://ugspace.ug.edu.gh 62 United Nation High Commissioner for Refugees (UNHCR).(2008)Vulnerable GroupSurvey:reproductive health in refugee Situition: An inter Agency field Manual, Geneva USAID (2011). Level,trends and determinants of contraceptive use among adolescents girls in Kenya.pg vi Waldman, W.,&Francoise.G.(2000).ensuring the reproductive rights of refugees and internally displaced persons: legal and policy issues advancing sexual and reproductive worldwide through research,policy analysis and public education.V.26.number 4. Watts M.& Mcmichael C. (2014) Factors Influencing Contraception Awareness and Use: The Experiences of Young African Australian mothers. Journal of Refugee Studies (2015) 28 (3): 368-387. doi: 10.1093/jrs/feu040 First published online Westley, E., Kapp, N., Palermo, T., & Bleck, J. (2013). International Journal of Gynecology andObstetrics review article a review of global access to emergency contraception. International Journal of Gynecology and Obstetrics, 3–5. http://doi.org/10.1016/j.ijgo.2013.04.019 WHO. (2015). literature. United Nations, Department of Economic and Social Affairs, Population Division (2015).Update for the MDG Database: Contraceptive Prevalence (POP/DB/CP/A/MDG2015). http://doi.org/(OP/DB/CPP/A/MDG2015 Williamson, L. M., Parkes, A., Wight, D., Petticrew, M., & Hart, G. J. (2009). Limits to moderncontraceptive use among young women in developing countries : a systematic review of qualitative research, 12, 1–12. http://doi.org/10.1186/1742- 4755-6-3 University of Ghana http://ugspace.ug.edu.gh 63 APPENDICES APPENDIX A: INFORMED CONSENT FORM Project Title: Modern contraceptive use among young women in Budumburam refugee camp in Ghana General information about the study This is a research study being undertaken as a requirement in the University of Ghana, School of Public Health, Legon to attain a master’s degree in public health. This study is to help gain a better understanding of modern contraceptive use among young women in Budumburam refugee camp in Ghana. Despite a lot of studies done on modern contraceptive use among young women globally and in Ghana, much of such studies have not been done in the Budumburam refugee camp although young women in the refugee camp who engage in risky behaviors are at high risk of sexually transmitted infections including HIV and unwanted pregnancy. This study is being done because of the increase risk of STI/HIV infections, unwanted pregnancy and abortion among young women between 15-24 years of age. The purpose of this study is to investigate the use of modern contraceptive among young refugee women in the Budumburam refugee camp in Ghana. The duration of the study will be less than a year. Findings during this period will enable us identify the use of modern contraceptive among young refugee women in the Budumburam refugee camp in Ghana and to address gaps that lead to STIs including HIV and unintended pregnancy and its consequences among young women in the refugee camp. University of Ghana http://ugspace.ug.edu.gh 64 Procedures Young women aged 15-24 years from Budumburam refugee camp will be used in this study. If you are eligible and agree to participate, you will be required to complete structured questionnaire. We will ask you questions about your background, sexual life and contraception knowledge, socio-economic and cultural issues and health facility related issues. Each respondent is expected to use about 30 minutes each to complete the questionnaire. Possible Risks and Discomforts The study may involve some risks. Anticipated risk such as some discomfort during the process answering sensitive and intimate questions due to the nature of the topic. Some of the questions focus directly on your personal life, and you may feel some discomfort answering those questions. You are free to ignore any questions you are not comfortable with. Possible Benefits There is no direct benefit to the participants of this study. The findings of this study will help us to suggest improved ways of intervention to reduce unwanted pregnancy within the refugee camp and improve the general health and well-being for young women in refugee camp in Ghana and Africa as a whole. Voluntary Participation and Right to Refuse Your participation in this study is voluntary. During the filling of the questionnaire, you can choose to ignore any questions that you are uncomfortable with and also at liberty to University of Ghana http://ugspace.ug.edu.gh 65 withdraw from the study at any time. However, we will encourage you to participate and complete the questions since your opinions are very important to us. Confidentiality Though we would be glad if you take part in the study, neither you nor the study will be affected or suffer if you decide not to take part in the study. All the information will be kept confidential and the data will be stored in a locked cabinet. Access will be limited to only the researcher and research supervisor. Your name, identity are not needed for the study. However, the information you would be treated strictly confidential. We assure you that your name shall not appear or be mentioned in any report that might come out from this study. Compensation There is no compensation for participating in this study. Participant voluntary consent I _________________________________________, declare that the above document describing the purpose, procedures as well as risks and benefits of the research titled “(modern contraceptive use among young women in Budumburam refugee camp in Ghana)” has been thoroughly explained to me in English language. I have been clearly informed that there is no compensation for this study. I have been given the opportunity to ask any questions about the research and answered to my satisfaction. I hereby voluntarily agree to participate as a subject in this study. Signature of Participant …………………… Date……………………………. University of Ghana http://ugspace.ug.edu.gh 66 Consent form for parents of participants below 18 years I _________________________________________, declare that the above document describing the purpose, procedures as well as risks and benefits of the research titled “(modern contraceptive use among young women in Budumburam refugee camp in Ghana)” has been thoroughly explained to me in English language. I have been clearly informed that there is no compensation for this study. I have been given the opportunity to have any questions about the research answered to my satisfaction. I hereby voluntarily agree on behalf of my ward below 18 years to participate as a subject in this study. Signature of parent of participant…………………….. Date …………………. Assent for those below 18 years I _________________________________________, declare that the above document describing the purpose, procedures as well as risks and benefits of the research titled “(modern contraceptive use among young women in Budumburam refugee camp in Ghana)” has been thoroughly explained to me in English language. I have been clearly informed that there is no compensation for this study. I have been given the opportunity to have any questions about the research answered to my satisfaction. I hereby voluntarily agree to participate as a subject in this study. Signature of Participant…………………. Date……………………… University of Ghana http://ugspace.ug.edu.gh 67 Interviewer’s statement I, __________________________________________, certify that the nature and purpose, the potential benefits and possible risks associated with participating in the study have been explained to the above individual in the English language. The participant has freely agreed to participate in the study. ________________________________ _______/_____/__________ Signature of person who obtained consent Date University of Ghana http://ugspace.ug.edu.gh 68 University of Ghana School of Public Health APPENDIX B: QUESTIONAIRE Project Title: Modern contraceptive use among young refugee women in Budumburam refugee camp Participant instructions Do not write your name; tick only one correct response and multiple responses where applicable. Only young people aged between 15-24 years are eligible for this study. Respondent code: Date of interview: (dd/mm/yy) _____/_____/_____ Name of research assistant… Zone… A. SOCIO-DEMOGRAPHIC BACKGROUND 1. Which country do you come from? a. Liberia [ ] b. Sierra Leone [ ] c. Ivory Coast [ ] d. Ghana [ ] e. Other, please specify ……………………… 2. How many years have you been living in the camp? a.1-3 [ ] b. 4-6 [ ] c. 7-9 d. 10-12 [ ] e. 13-15 [ ] f. Other, please specify…………. 3. How old are you? a. 15-19 [ ] b. 20 -24 [ ] 4. Highest level of education: a. none [ ] b. Primary [ ] c. JHS d. Secondary [ ] e. Tertiary [ ] f. Other, please specify…………. University of Ghana http://ugspace.ug.edu.gh 69 5. Religious affiliation: a. Christianity [ ] b. Islamic [ ] c. Traditional [ ] d. Other, please specify………………………………………… 6. Marital Status: a. Married [ ] b. Not married [ ] c. Divorced [ ] d. Separated [ ] e. co-habiting [ ] f. Other, please specify ……………………… 7. Occupation a. student [ ] b. worker [ ] 8. Who do you stay with? a. Parents [ ] b. Guardian [ ] c. Partner [ ] d. By myself [ ] 9. What is the highest level of education of your mother? a. None [ ] b. Primary [ ] c. JHS [ ] d. Secondary [ ] e. Tertiary [ ] f. Other, please specify ………. 10. What is the highest level of education of your father? a. None [ ] b. Primary [ ] c. JHS [ ] d. Secondary [ ] e. Tertiary [ ] f. Other, please specify ………. 11. Occupation of father a. none [ ] b. self-employed [ ] c. government worker [ ] 12. Occupation of mother a. none [ ] b. self-employed [ ] c. government worker [ ] 13. Occupation of other Guardian a. none [ ] b. self-employed [ ] c. government worker [] B. Awareness and Knowledge of Modern Contraceptives 14. Have you ever heard about contraception? a. Yes [ ] b No [ ] 15. If yes, how did you hear about it? Radio [ ] Teacher [ ] Health worker [ ] Family member [ ] Friends [ ] Partner [ ] Print media [ ]. Others specify [ ] ………………. 16. Contraception is any method or procedures used to prevent pregnancy? a. Yes [ ] b No [ ] c. Don’t know [ ] 17. Have you ever heard of any contraceptive methods before? a. Yes [ ] b. No [ ] University of Ghana http://ugspace.ug.edu.gh 70 18. Have you heard of modern contraceptives? a. Yes [ ] b. No [ ] 19. If yes, mention the methods that you know a. IUD [ ] b. Injectable [ ] c. Implants [ ] d. Pills [ ] e. Female condom [ ] f. Male condom [ ] g. Diaphragm [ ] h. Lactational Amenorrhea Method [ ] i. Others (specify) ……………………………………………….. 20. Where did you hear of this contraceptive(s) you have mentioned in 18 above? a. Radio [ ] b. Teacher [ ] c. Health worker [ ] d. Family member [ ] e. Friends [ ] f. Partner [ ] g. Print media [ ]. H. Others specify [ ]…………………. 21. Do you know a place in your community where you can get a modern contraceptive? a. Yes [ ] b. No [ ] 22. If yes, where? a. Hospital /Clinic [ ] b. Pharmacy/Drug store [ ] c. Health provider [ ] d. Family Planning/PPAG Clinic [ ]. e. Friend [ ] f. Other specify ……………… 23. Can a girl become pregnant from just one unprotected sex? a.Yes [ ] b. No [ ]. c. Don’t know [ ] d. Other specify ……………… 24. Do you think that using modern contraceptive during sex provide 100% protection from pregnancy? a. Yes [ ] b. No [ ]. c. Don’t know [ ] d. Other specify ……………… 25. Do you think that using modern contraceptive during sex provide 100% protection from sexually transmitted infections? a. Yes [ ] b. No [ ] University of Ghana http://ugspace.ug.edu.gh 71 26. Overall, do you think contraception is a woman’s business and a man should not have to worry about it? a. Yes [ ] b. No [ ] 27. Over all, do you think women who use contraception may become promiscuous? a. Yes [ ] b. No [ ] C. Attitudes and Modern Contraceptive use 28. Have you ever had sex before? a. Yes [ ] b. No [ ] If No skip to question 30 29. How old were you when you first had sexual encounter? a.15-19 [ ] b. 20-24[ ] c. none [ ] 30. Have you used any contraceptive before? a. Yes [ ] b. No [ ] If No skip to question42. 31. If yes to Q30, which of the methods have you used? a. IUD [ ] b. Injectable [ ] c. Implants [ ] d. Pills [ ] e. Female condom [ ] f. Male condom [ ] g. Diaphragm [ ] h. Lactational Amenorrhea Method [ ]. i. None [ ] j. Others (specify) ……………… 32. Are you currently using any modern contraceptive? a. Yes [ ] b. No [ ] If No skip to question 34 33. If yes, which of the methods are you currently using? a. IUD [ ] b. Injectable [ ] c. Implants [ ] d. Pills [ ] e. Female condom [ ] f. Male condom [ ] g. Diaphragm [ ] h. Lactational Amenorrhea Method [ ]. i. None [ ] j. Others (specify) ……………… 34. Where do you get this modern contraceptive in the municipality from? a. Hospital /Clinic [ ] b. Pharmacy/Drug store [ ] c. Health provider [ ] d. Family Planning/PPAG Clinic [ ]. e. Other specify ……………… University of Ghana http://ugspace.ug.edu.gh 72 35. How long have you been using modern contraceptives? a. Less than one year [ ] b. One to two years c. Three to five years [ ] d. Six to 10years [ ] e. Others (specify) ……………… 36. How often do you use any of the methods? a. Every time [ ] b. Once a while [ ] c. Not at all [ ]. d. Don’t know [ ] e. Others (specify) ……………… 37. What are your reasons for using modern contraceptives? a. To avoid teenage pregnancy [ ] b. To prevent STIs [ ] c. To delay childbirth [ ]. d. Others (list) …………………………… 38. Who in your opinion should use modern contraceptives? a. Married couples only [ ] b. All sexually active persons [ ]. c. Adults only [ ] d. Other specify ……………… 39. The last time you had sex did you or your partner use any contraceptive? a. Yes [ ] b. No [ ] If No skip to question 41. 40. If yes to Q 39, which method of contraceptive did you use? Tick as appropriate. Methods Tick Methods Tick Female sterilization Condom( female& male) Implants Injectable Pills IUCD Spermicides Diaphragm Lactational amenorrhoea Male sterilization Others 41. The last time you used a contraceptive who decided on what to use? Influence Tick You University of Ghana http://ugspace.ug.edu.gh 73 Friend Partner Parent Others specify 42. If you wanted to, could you yourself get any modern contraceptives? a. Yes [ ] b No [ ] 43 If yes to Q42, which modern contraceptives could you yourself get? a. IUD [ ] b. Injectable [ ] c. Implants [ ] d. Pills [ ] e. Female condom [ ] f. Male condom [ ] g. Diaphragm [ ] h. Lactational Amenorrhea Method [ ]. i. None [ ] j. Others (specify) ……………… 44. Do you currently have a sexual partner (boyfriend/girlfriend)? a. Yes [ ] b No [ ] 45. How many sexual partners (boyfriend/girlfriend) have you had in your lifetime? a.1-3 [ ] b. 4-6 [ ] c. 7-9 d. 10-12 [ ] e. 13-15 [ ] f. Other, please specify…………. 46. Within the last 12 months, how many sexual partners have you had? a.1-3 [ ] b. 4-6 [ ] c. 7-9 d. 10-12 [ ] e. 13-15 [ ] f. Other, please specify…………. 47. Have you ever had sexual intercourse while drunk? a. Yes [ ] b No [ ] If No skip to question 49 48. If yes to question 47, did you or your partner use any modern contraceptive? a. Yes [ ] b No [ ] 49. Do you feel any pressure from others to have unprotected sexual intercourse? a. Yes [ ] b No [ ] If No skip to question 51. University of Ghana http://ugspace.ug.edu.gh 74 50. If yes to question 49, from whom do you feel the pressure? a. Friends [ ] b. Relatives [ ] c. Partner [ ]. Other specify ……………… 51. Do you think sex education can influence modern contraceptive use? a. Yes [ ] b. No [ ] 52. Did you get education on sex in school? a. Yes [ ] b. No [ ]. c. Don’t know [ ] d. Not applicable [ ] 53. Did you get education on sex in the house? a. Yes [ ] b. No [ ]. c. Don’t know [ ] d. Not applicable [ ] 54. Did you get education on sex in the church/Mosque? a. Yes [ ] b. No [ ]. c. Don’t know [ ] d. Not applicable [ ] D. Factors Influencing Use of Modern Contraceptives 55. Is there any cultural beliefs and practices that prevent the use of modern contraceptives among young women in your community? a. Yes [ ] b. No [ ] c. Don’t know [ ] If No skip to question 57. 56. If yes to question 55, can you mention them ……………………………………………….. …………………………………………………………………………………………… …………………………………………………………………………………………… …………………………………………………………. 57. Is there any religious beliefs and practices that prevent the use of modern contraceptives? a. Yes [ ] b. No [ ] c. Don’t know [ ] If No skip to question 59 58. If yes to question 57, can you mention them……………………………………………….. …………………………………………………………………………………………… ………………………………………………………………………………………….. University of Ghana http://ugspace.ug.edu.gh 75 59. What will you say are the reasons why young women in your community do not use contraceptives?(Can tick more than one) Factor Tick a. Religious beliefs b. Distance to acquisition of contraceptives c. Attitude of the contraceptive providers d. Partner or family members opposed to using e. Side effects f. Lack of knowledge g. Infrequent sex h. Hard to get preferred methods i. Too costly j. Counselling received about contraceptives k. Cultural or traditional beliefs l. Other, specify………………………………………………………………… ………………………………………………………………………………….. E. Measures to improve modern contraceptive use Tick the one(s) that apply to you. 1-Strongly agree; 2- Agree; 3-Disagree; 4-Strongly disagree No. Item Scale 1 2 3 4 60 Enough modern contraceptives logistics to provide services. 61 Frequent advertisement on social media 62 Policies on contraceptives should be implemented 63 The modern contraceptives and related services should be free. 64. Overall, how do you think use of modern contraceptives among young women in the camp could be improved? a. Yes [ ] b. No [ ] Please, explain your response …………………………………………………………….……………………………… …………………………………………………………………………………………… University of Ghana http://ugspace.ug.edu.gh 76 ETHICAL APPROVAL LETTER University of Ghana http://ugspace.ug.edu.gh 77 University of Ghana http://ugspace.ug.edu.gh 78 University of Ghana http://ugspace.ug.edu.gh