ASSESSMENT OF KNOWLEDGE, ATTITUDE, AND PRACTICE TOWARDS EMERGENCY CONTRACEPTIVES AMONG FEMALE COLLEGE STUDENTS AT MEKELLE TOWN, TIGRAY REGION, ETHIOPIA: A CROSS SECTIONAL STUDY

ASSESSMENT OF KNOWLEDGE, ATTITUDE, AND PRACTICE TOWARDS EMERGENCY CONTRACEPTIVES AMONG FEMALE COLLEGE STUDENTS AT MEKELLE TOWN, TIGRAY REGION, ETHIOPIA:  A CROSS SECTIONAL STUDY

Haftom Gebrehiwot*, Berhane Gebrekidan, Haftu Berhe and Kalayou Kidanu

Department of Midwifery & Nursing, Mekelle University & AAU, Mekelle, Ethiopia

ABSTRACT:

Background: Death related to unintended pregnancy associated events is a series public health concern in Ethiopia. This is very common in young adolescents for whom life is full of adventure and temptation with very little knowledge about the consequences of their reckless activities. Emergency contraceptives are the only method that can be used within short time after sexual intercourse, offering a second chance to prevent unwanted pregnancy.

Objectives: To assess the knowledge, attitude and practice of emergency contraceptives among female college students at Mekelle town, Ethiopia.

Methods: An institutional based cross-sectional survey was conducted among 616 female college students at Mekelle town from March to July, 2011. Multistage sampling technique with Probabilities proportional to size was used. Data were analyzed by SPSS window version 16.0 software package and presented using frequencies, percentages. Crude & adjusted odds ratio were used to control the possible confounding variables.

Results: Of the total respondents, 393(67.3%) of them replied that they have heard about emergency contraceptives. Among those who have ever heard of emergency contraceptives, 224 (57%) mentioned pills only, 9 (2.3%) mentioned intrauterine contraceptive devices only and 154(39.2%) mentioned both pill & IUCDs. 263(45%) of the respondents were knowledgeable towards ECs, and about 271(46.4%) of the students had positive attitude towards emergency contraceptives. Of the sexually active respondents 70(24.2%) only reported that they had used emergency contraceptive methods previously. Whereas, 219(75.8%) were not used emergency contraceptives; some of the reasons were lack of knowledge about ECs (42.9%); no desire to use (22.8%) and inaccessibility toward emergency contraceptives (16.4%).

Conclusion: The study indicated low level of knowledge; very low level of practice and majority showed negative attitude towards emergency contraceptives.

Emergency contraceptive, Knowledge, Mekelle, College students

INTRODUCTION: Emergency Contraception (EC) refers to a group of birth control modalities that, when used after an unprotected intercourse or contraceptive failure within defined time limits; can prevent an unwanted pregnancy ^{1, 2}.

EC has different terminologies like: morning after pill, post coital contraception, and second chance [3]. There are two types of emergency contraception: hormonal methods (pills) and the insertion of intrauterine device (IUD). Hormonal emergency contraception pill consists of:

i)        Combined oral contraceptive pills: taken within 72 hours of unprotected intercourse and then 12 hours later.

ii)      Progesterone only pills: one pill should be taken as the first dose as soon as convenient, but not later than 3 days (72 hours) after unprotected intercourse to be followed by another one pill 12 hours later.

Another, method of emergency contraception/ Post coital insertion of a copper- releasing IUD was 1^st reported in 1976 ^{3, 4, 5, 6}.

Emergency Contraception is largely underutilized worldwide and has been referred to as one of the best kept secrets in Reproductive Health (RH) ^[7]. It can reduce the number of unwanted pregnancies and is unique in that it is the only immediate option left for somebody who has had unprotected intercourse and is not ready for a pregnancy.

For many women, emergency contraception (EC) offers a final opportunity to prevent unwanted pregnancy after they have had unprotected sexual intercourse, have experienced a contraceptive failure, have remembered too late that they have forgotten to take their birth control pills, or have been forced to have sex against their will (rape) ^{8, 9, 10,11}. Unplanned pregnancies among young women are a worldwide problem with social and economic repercussions for the unprepared young individual ¹². A critical challenge in the global effort to reduce maternal mortality is the persistence of unsafe abortion as a result of unwanted pregnancy, which accounts for 13% of Pregnancy related deaths worldwide ^{12, 13}.

In many low income countries, the lack of knowledge about and access to EC may result in women resorting to unsafe abortions, which contribute significantly to maternal morbidity and mortality. Each year, about 210 million women around the world become pregnant. Among them, about 75 million pregnancies (36%) are unplanned and/or unwanted.  And globally, more than 20 million women experience ill health as a result of pregnancy each year ^{11, 13, 14, 15}.

Each year, an estimated 19 million unsafe abortion occurs in the developing world, and around 70,000 women die from abortion-related causes where abortion is often legally restricted and maternal care services are lacking. In addition to those who die from unsafe abortions, tens of thousands suffer from chronic and sometimes irreversible health consequences, including infertility ^{16, 17, 18}. Emergency contraception (EC) as a backup method is new in Ethiopia. Various reports show that there is little knowledge and information available about EC in the country.

Unsafe abortion as a result of unplanned/unwanted pregnancy is one of the leading causes of maternal mortality and morbidity in Ethiopia. Ethiopia has a high incidence of unwanted pregnancies and unsafe/septic abortions, particularly among adolescents ^[19,20,21]. Therefore, this study is needed because Emergency contraceptives play a vital role in preventing unwanted pregnancies, induced abortions and would serve as a backup to other family planning methods ²².

METHODOLOGY:

Study setting: The study was carried out between March, 2011 to July 2011 at Mekelle town. Mekelle is the capital city of Tigray Administrative regional state, located approximately 783 kilometers north part of Addis Ababa, the capital city of Ethiopia.  The town is divided in to seven administrative localities. In the town there are four governmental and fifteen private colleges, including social science educations, health science colleges, technical and vocational colleges which run in diploma and degree programs. An institution based cross - sectional study design was conducted. The primary population source of the study was all college female students in Mekelle town who were attending their education during the study period and Study population were Female students who were randomly selected from Mekelle health Science College, SDC Mekelle TVET, and Sheba College in Mekelle town. The sample size was determined using single population proportion formula assuming the proportion of students who are aware of ECs is to be 50%. Adding non response rate of 10%, and multiplying by a design effect of 2 due to the multistage nature of the sampling method. The required samples based on the usual formula were 616.

After calculating the sample size, the multistage stratified sampling were employed considering all governmental and private colleges/ institutions in Mekelle town, streams or departments and year of study in the sampling process for the selection of the study subjects.Initially, of the whole nineteen governmental and private college institutions in the town three institutions, Mekelle health Science College, SDC Mekelle TVET and Sheba College were selected randomly and the total sample size of the study were distributed over each of the institute proportional to their size.

In the second stage, departments/streams from the selected college were selected using simple random sampling (SRS) technique. Accordingly the sample size of the study allocated to each institute was distributed to each of the stream and department proportional to their size.

Finally, the required numbers of female students were selected randomly (applying SRS) from each year of study again proportional to their size from the randomly selected departments. For this study a self administered structured questionnaire were conducted. The questionnaires contain open as well as closed ended questions which covers socio demographic information, knowledge, attitude and practice on emergency contraceptive. This were prepared in English and translated to Tigrigna and then turn to English for its consistency. After the data collection, each questionnaire was checked for its completeness. Data cleaning and editing as well as coding were done by EPi Info version 3.5.1 statically soft ware package & enter in to SPSS window version 16.0 soft ware for analysis purpose.

The independent variable were socio demographic characteristics- age, marital status, religion, place of origin, years of study, and residence and the outcome variable was Knowledge, attitude and practice (KAP) of emergency contraceptives.

The research permission was obtained from the Institution review board of department of midwifery and nursing, college of health science, AAU. A formal letter was written to   Tigray regional health bureau and permission to carry out the study was obtained from the regional health bureau to conduct the study in the selected sites of Mekelle town colleges.

Verbal consent was obtained from the study participants after explaining the objective and procedure of the study. Confidentiality was maintained and assured by excluding their names from identification of the study subject.

RESULTS:

Socio - Demographic characteristics of Respondents: Out of total 616 female college students 584 were included in the study with a responses rate of 94.8%. Most of the respondents 301 (51.5%) were within age group of 20-24 years. and ranged from a minimum of 16 years to a maximum of 43 years. Majority of the study subjects 579(98.1%) were from Tigray ethnic group. And 379 (64.9%) had urban background prior to their entry to the colleges, with the rest being from rural (Table 1).

Family Planning Knowledge, Attitude & Practices of The Respondents: Majority, 574 (98.3%) of female students in the study had ever heard about regular modern contraceptives. While only 10 students (1.7%) never heard about any family planning method in their life time. Knowledge of modern contraception 476(82.9%) of respondents knew condom type of contraception, 442(77.0%) oral pill, 452 (78.7%) Injectable, 260(45.3%) Norplant, 238(41.5%) calendar, 233(40.6%) IUCD & 4(0.7%) followed by other type of contraceptive methods.

The common sources of information were 289(50.3%) from health institution and 226(39.4%) from school (Table 2).

 TABLE 1:  SOCIO - DEMOGRAPHIC AND ACADEMIC CHARACTERISTICS AMONG FEMALE COLLEGE STUDENTS AT MEKELLE TOWN, JUNE, 2011

TABLE 2: KNOWLEDGE, ATTITUDE AND PRACTICE ABOUT REGULAR TYPE OF CONTRACEPTIVES AMONG FEMALE COLLEGE STUDENTS IN MEKELLE TOWN, JUNE, 2011  

* refers some respondents have multiple responses

Most of the respondents, 558(95.5%) also believed that contraceptives are important in preventing unwanted pregnancy. 232(39.7%) of the respondents were ever used contraceptive methods and the most commonly used method was Injectable 153(65.9%) followed by oral pill 68 (29.3%) (Figure 1).

FIGURE 1: PERCENTAGE OF TYPE OF MODERN REGULAR CONTRACEPTIVES USED BY THE RESPONDENTS.         

Emergency Contraceptive Knowledge, Attitude & Practices among Mekelle Female College Students:

Awareness and Knowledge of Emergency Contraceptive: This study examined the awareness of respondents about EC prior to the assessment of their detailed knowledge. According the survey findings, about 393 (67.3%) of the whole respondents ever heard about ECs. In addition, When asked about specific types of emergency contraceptives, among those who had ever heard of emergency contraceptives, 224 (57.0%) mentioned oral pills and 154 (39.2%) mentioned both oral pills and IUCDs, 9(2.3%) mentioned IUCD only, and 6(1.5%) followed by others (Table 3).

TABLE 3: PERCENTAGE DISTRIBUTIONS OF FEMALE COLLEGE STUDENTS BY ECS AWARENESS IN MEKELLE TOWN, JUNE, 2011

The main sources of information about emergency contraceptive were health institution about 168(42.7%), followed by class teacher 100(25.4%). (Figure 2).

FIGURE 2: MAIN SOURCES OF INFORMATION ON EMERGENCY CONTRACEPTIVE AMONG RESPONDENTS WHO HAVE HEARD ABOUT IT.

Of those respondents who were aware of emergency contraceptives, 260(44.5%) correctly identified the recommended time limit to be taken, i.e. combined ECPs within 72 hours after un protected sex. 108(18.5%) correctly knew the effectiveness of ECPs in preventing un wanted pregnancy, 159(27.2%) and 188 (32.2%) of the respondents also identified the recommended number of doses and the recommended time between the doses of ECPs, respectively. Forced sex or rape (45.9%) and accidental breakage or slippage of condom (33.6%), missed pills (32.7%) and followed by failure of contraceptives (25%) stated as appropriate situation to use ECs to prevent unintended pregnancy (Table 4).

Regardless of IUCD emergency contraception, of those who were aware of emergency contraceptive method, 130(22.3%) stated the correct timing of administration of IUCD which is after the unexpected sexual contact, and 198(33.9%) were correctly identified its effectiveness in preventing unintended pregnancy. By computing the knowledge questions of the respondents the mean value was 2.33, median of 2.00 and S.D of 1.47.  Therefore, regardless of knowledge of ECs summary index below, majority of the respondents, 321(55.0%) were not knowledgeable. (Table 4)

TABLE 4: KNOWLEDGE REGARDING THE TIMING AND DOSING OF EMERGENCY CONTRACEPTIVE AMONG FEMALE COLLEGE STUDENTS, WHO KNOW ECS IN MEKELLE TOWN, JUNE, 2011

* refers some respondents have multiple responses 

Attitude towards emergency contraception and willingness for future use: As table 5 presents that, concerning the attitude assessment questions towards emergency contraceptives, the respondents score was with mean of 1.52, median 2.00 and SD 0.79.  Based on this majority of the students, 313 (53.6%) of them have negative attitude towards ECs.

TABLE 5: PERCENTAGE DISTRIBUTION OF FEMALE COLLEGE STUDENTS IN MEKELLE TOWN BY ATTITUDE TOWARDS EC, JUNE, 2011

Emergency Contraceptive practices and pregnancy related characteristics among sexually active female college students at Mekelle town: At the time of the study 289(49.5%) respondents have ever had sex in the past. Of those who are sexually active, about 243(84.1%) started sex before the age of 18 and 46(15.9%) started sex at 18 years of age and above. Regardless of the respondents having number of sexual partner in their life time, most of them, 226(78.2%) had one sexual partner.

Concerning rape, respondents who were sexually active in the past, 32(11.1%) of them were claimed to had sex without their consent or raped. With regard to pregnancy experience, on those who were sexually active, a total of 130(45.0%) respondents replied that they had been pregnant and with 65.4% gave a history of at least once pregnancy previously. And from the pregnant study subjects, 42(32.3%) had practiced induced abortion. On the other hand, those respondents who had heard of emergency contraceptives, only 70(24.2%) respondents reported that at least once they had used emergency contraceptive methods previously.

65(92.9%) of the participants said that they had used oral pills as type of emergency contraceptive methods, 3(4.3%) IUCDs  & 2(2.9%) both oral pill and IUCD type of ECs. Of the 219 respondents who had not ever used ECs, 94(42.9%) were due to lack of knowledge about Emergency contraceptives and 50(22.8%) hadn’t desire to use it (Table 6).

TABLE 6: ECS PRACTICE AND PREGNANCY RELATED CHARACTERISTICS AMONG SEXUALLY ACTIVE FEMALE COLLEGE STUDENTS AT MEKELLE TOWN, JUNE, 2011

* Remained some respondents have multiple responses

Determinants of Knowledge, Attitude and Practice Towards ECs:

Determinant factors related to knowledge about Emergency Contraceptives: In bivariate analysis, age group of female college students was found to be associated with the knowledge of EC; those respondents who were in the age group of 20-24 were 1.46 more knowledgeable compared to respondents who were in the age group of 15-19. As shown in table seven [COR=1.46, 95% CI (1.02, 2.09)]. But the association was insignificant after adjusting for possible confounders. The crude odds ratio result indicated that place of origin of the respondents prior to the entry to their college were also found to be significantly associated with knowledge of ECs; Students who were rural back ground prior to their entry to the college were more knowledgeable of ECs compared to students who were urban back ground [COR=1.47, 95%CI (1.04, 2.07)]. Marital status has a significant effect on knowledge of ECs among female students without controlling other variables; ever married female students were found to be 2.43 times more likely to be knowledgeable of ECs than those who are single and those divorced & widowed were also 2.39 times more knowledgeable than single female students. Were as the adjusted odds ratio of marital status was found insignificant when the other variables controlled.

Similarly according to crude analysis, number of life time sexual partner of the respondents was found to be negatively associated with the knowledge of ECs. The likelihood of ECs knowledge among respondents who had have more than one sexual partner was less by 46% compared with those who had have one sexual partner in their life time. [COR=0.54, 95%CI (0.38, 0.71)]. This output assured that female students having one sexual partner have more likely to be knowledgeable of ECs than those who have more than one sexual partner.

Adjusted for other variables, experience toward use of EC has to be a significant factor on respondents knowledge of EC; those who had not ever used ECs were found to be 0.38 times less likely to be knowledgeable towards ECs than those who had have an experience of use of ECs. As shown in table 7 [Adj.OR=0.38, 95% CI (0.21, 0.70)] (Table 7).

TABLE 7: SOCIO-DEMOGRAPHIC AND OTHER DETERMINANT VARIABLES OF KNOWLEDGE OF EC AMONG FEMALE COLLEGE STUDENTS OF MEKELLE TOWN, JUNE, 2011

* Remained statistically significant in both crude and adjusted odds ratio in the table.

Determinant factors related to Attitude about Emergency Contraceptives: The multivariate analysis disclosed that the extent of knowledge of respondents towards EC was a statistically significant factor for positive attitude towards EC and had a positive relation.

According to multivariate analysis, respondents who were knowledgeable have 2.48 times more likely to have positive attitude towards EC as compared with those who were not knowledgeable respondents. Table 8 [Adj. OR=2.48, 95% CI(1.34, 4.57)].

TABLE 8: SOCIO-DEMOGRAPHIC AND OTHER DETERMINANT VARIABLES OF ATTITUDE TOWARDS EC AMONG FEMALE COLLEGE STUDENTS OF MEKELLE TOWN, JUNE, 2011 (N = 584)

            * Remained statistically significant in both crude and adjusted odds ratio in the table.

Determinant factors related to Practice about Emergency Contraceptives: In Bivariate analysis, age group of the respondents was found to be associated with the practice of ECs. Those respondents who were in the age group of 20-24, 25-29 and 30 & above were less likely to  practiced ECs compared to those respondents who were in the age group of 15-19years. As shown in table 9 [COR=0.36, 95%CI (0.2, 0.7), 0.24(0.1, 0.6) and 0.19(0.06, 0.69)] respectively. But the association was insignificant after adjusting for possible confounders. The multivariate analysis also ascertained age at first sex of respondents as a statistically significant affecting factor of practice of EC.

As the result indicated, being 18 years and above had a positive effect on the likelihood of practice of EC as compared with being age at first sex below 18 years. Female students who ever had sexual intercourse at age of 18 years & above were found 7.01 times more likely to be practiced of EC than those who had sexual intercourse at age of below 18 years. [Adj. OR=7.01, 95% CI (1.28, 38.3)] as shown in table 9. Number of life time sexual partner of the respondents was found to be positively associated with practice of EC.

The likelihood of practice of EC among students who have more than one sexual partner was found to be 5.65 times more likely to be practiced ECs than those who have one sexual partner. [COR=5.65, 95% CI (3.24, 9.95)]. But it is insignificant after adjusting for possible confounders. Knowledge of respondents towards ECs was found to be negatively associated with the practice of ECs; the likelihood of practice of ECs among respondents who were knowledgeable of EC was less by 74% as compared with those who were not knowledgeable towards ECs. [COR=0.26, 95% CI (0.15, 0.46)]. But the association was insignificant after adjusting for possible confounders(Table 9).

TABLE 9: THE SOCIO-DEMOGRAPHIC AND OTHER DETERMINANT VARIABLES OF PRACTICE TOWARDS EC AMONG FEMALE COLLEGE STUDENTS OF MEKELLE TOWN, JUNE, 2011 (N = 584)

* Remained statistically significant in both crude and adjusted odds ratio in the table.

DISCUSSION: Although emergency contraception is not recommended as a regular family planning method, it is the most useful as a group of birth control modalities, when used after an unprotected inter-course or contraceptive failure within defined time limits ². The result from this study revealed that greater than two-third (67.3%) of the respondents had heard of the emergency contraception method. This is lower than the reports on studies in San Francisco (89%). This could be due to low health promotion and low availability of EC in developing country like Ethiopia. It is comparable to reports from Katmandu- Nepal (68%) ^{21, 26} & Jimma university community high school (64%) ³.

The mean age of respondents of this study was approximately 20 years. More than half (57%) had ever heard emergency contraceptive pills. The most common source of information was health institution (42.7%), class teacher (25.4%), club in the school (21.6%), mass media (17%) and friend (7.6%). This showed higher than studies conducted on Uganda, Makerere University among University Students with  the mean age of the participants was 21 years and Less than half (45.1%) had ever heard about emergency contraceptive pills (ECPs) and their most common sources of information about EC were friends (34%), media (24.8%) and schools (19.4%) ¹⁰.

Almost half of the total number of my study subjects (49.5%) reported that they were sexually active in their lifetime with 84.1% of the respondents had first sex at age below 18 years. Majority of the respondents (53.6%) had negative attitude towards ECs. 39.7% had ever practiced regular type of contraception with only 24.2% having ever practiced emergency contraception.

However, Of those respondents who are aware of emergency contraceptives, (44.5%) correctly identified the recommended time limit to be taken combined ECPs within 72 hours after un protected sex, (18.5%) correctly knew the effectiveness of ECPs in preventing un wanted pregnancy, (27.2%) and (32.2%) of the respondents also identified the recommended number of doses and the recommended time between the doses of ECPs, respectively. This finding is lower in level of Knowledge and practice rate of ECs than studies reported among female undergraduates in the University of Lagos, Nigeria, which revealed that 67.8% of the respondents reported knowing about emergency contraception with more than half (56.1%) were sexually active and of this group, 96.8% had ever practiced contraception with only 33.9% having ever practiced emergency contraception ²⁷.

However, only 37.8% and 36.3% of respondents who had reported knowing about emergency contraception knew the correct time frame for effective use, and correctly identified emergency contraceptives respectively ^{24, 36}. The possible reason for low EC practice rate and knowledge in this study could be due to having negative attitude towards emergency contraception, lack of correct information, low promotion and availability of the methods in most health institutions as well as lack of enough mass Medias that works about reproductive health condition of the society.

This study revealed that 69.2% of female students of Mekelle College of health science, SDC Mekelle TVET and Sheba College who had heard about EC would like to use emergency contraceptives in the future, 18.3 percent would not, while 12.5 percent were unsure. This finding explained that less intention to use ECs in the future than studies obtained in Awassa town, south part of Ethiopia in which about 80 percent of female college students who had heard about EC would like to use emergency contraceptives in the future, 15.6 percent would not, while 4.2 percent were unsure. The possible reason for this may be: due to lack of awareness of ECs as well as due to mass Media in adequacy in Tigray region ²¹.

Among the respondents who were sexually active, about 45% become pregnant & of them 65.4% gave history of at least one pregnancy with 32.3% had induced abortion. On the other hand, among the total study participants, about 84.1% had first sex at age of below 18 years, 11.1% ever had sex without their consent, of which 53.1% were unintended pregnancy, which is higher than studies done in Oremia region, Wolliso town ³.

The extent of knowledge of respondents towards EC was a statistically significant factor for positive attitude towards EC and had a positive relation. The likelihood of positive attitude increased as the extent of knowledge of EC increased.

These respondents who were knowledgeable have more likely to have positive attitude towards EC as compared with those who have not knowledgeable respondents, which is consistent as study conducted in Awassa town ²¹. Adjusted analysis of age at first sex of respondents was statistically significant affecting factor to practice of EC; being 18 years and above had a positive effect on the likelihood of practice of EC as compared with being age at first sex below 18 years, [Adj.OR=7.01,95%CI(1.28, 38.3)] ²¹.

CONCLUSION AND RECOMMENDATIONS: College female students are expected to have greater knowledge of EC than most youth with no or less educational attainment. This study has shown that 67.3 percent of the female college students have awareness about EC and Even among those who were aware, only 45 percent had adequate knowledge of ECs, 46.4% positive attitude toward the methods. The female students’ attitude towards EC was significantly associated with their level of knowledge about the method (Adj.OR=2.48) as stated by the adjusted analysis.

The finding revealed that the likelihood of positive attitude increased as the extent of knowledge of EC increased. Respondents who had adequate knowledge of EC were found 2.48 times more likely to have positive attitude towards EC than those who were not knowledgeable on EC. On the other hand, practice of EC is very low with high risk of unintended pregnancy and induced abortion among the sexually active students. This finding strongly suggests that adequate knowledge of the method and its availability is lacking among the female college students.

Hence, there is a need to educate adolescents about ECs, with emphasis on the correct time limit for use, the situation when they use it and accurate message about its effect on health. Moreover, health education program should be set up to the college students to avail accurate information about emergency contraception and existing "Reproductive Health Clubs" in the college could be the venue for disseminating similar information.

ACKNOWLEDGMENTS: Our deepest gratitude goes to Addis Ababa University for sponsoring the research. And we would like to extend our sincere gratitude to the data collectors, supervisors and the study participants for being involved in the study.

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    How to cite this article:

    Gebrehiwot H, Gebrekidan B, Berhe H and Kidanu K: Assessment of Knowledge, Attitude, and Practice towards Emergency Contraceptives among Female College Students at Mekelle Town, Tigray Region, Ethiopia:  A Cross Sectional Study. Int J Pharm Sci Res 2013; 4(3); 1027-1038.

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