Family Planning Knowledge, Attitudes and Practices Among Rohingya Women Living in Refugee Camps in Bangladesh: A Cross-Sectional Study

Background: Considering more than 720,000 Rohingya into Bangladesh, unplanned pregnancy, and serious complications of pregnancy among refugees, this study aims to explore the knowledge, attitude, and practice (KAP) of family planning (FP) and associated factors among the Rohingya women living in the refugee camps in Cox’s Bazar, Bangladesh. Methods: Four hundred Rohingya women were investigated, and data were collected using a structured questionnaire, which included socio-demographic characteristics, awareness of contraceptive methods, knowledge, attitudes and practices on FP. Linear regression analysis was performed to identify the predictors of outcome variables. Results: Of the Rohingya refugee women, 60% were unaware that there is no physical harm in adopting a permanent method of birth control. Half of them lack proper knowledge of whether a girl was eligible for marriage before the age of 18. More than two-thirds think family planning methods should not be used without the husband’s permission. Besides, 40% were ashamed and afraid to discuss family planning matters with their husbands, considering it as a sin. Of them, 58% had the opinion that a couple should continue bearing children until a son is born. Linear regression analyses demonstrated that Racidong in Myanmar as the region of residence, being professional, number of children, physician/nurse being the source of FP knowledge, having FP interventions in the camp, participating in a FP program, visiting a health facility, and talking with a health care provider on FP were signicantly associated with Rohingya women’s better KAP of FP. Conclusions: The study showed that Rohingya refugee women are a marginalized population in family planning and the comprehensive FP-KAP capability was low. Contraceptives among the Rohingyas are unpopular, mainly due to a lack of education and family planning awareness. In addition, family planning initiatives among Rohingya refugees were limited by some traditional cultural and religious beliefs. Therefore, strengthening FP interventions and increasing the accessibility to essential health services and education are indispensable in order to improve maternal health among refugees. This study uses a quantitative research approach designed with a camp-based cross-sectional survey. It was conducted at Rohingya refugee Camp-4 (located at Lombashiya, Modhurchora in Kutupalong Mega area) in Cox’s Bazar, a district under the Chittagong division, geographically the largest of the eight administrative divisions of Bangladesh. We selected this camp as the study area as it is one of the largest camps.


Study design and setting
This study uses a quantitative research approach designed with a camp-based cross-sectional survey. It was conducted at Rohingya refugee Camp-4 (located at Lombashiya, Modhurchora in Kutupalong Mega area) in Cox's Bazar, a district under the Chittagong division, geographically the largest of the eight administrative divisions of Bangladesh. We selected this camp as the study area as it is one of the largest camps.

Participants
Rohingya refugee married women of reproductive age (above 18 to 49 years) who were living with their husbands at the camps in the study area and had delivered at least one child at least one year before the survey were incorporated as the participants. The sample size was determined using the single population proportion formula considering the following assumption: p = 50% (it was hypothesized that the percentage frequency of outcome in the population was 50% for the estimated proportion of Rohingya women having better FP-KAP), signi cance level 5% (α = 0.05), Z α 2 = 1.96, margin of error 5% (d = 0.05). The required sample size was 384. Finally, a total of 400 refugee women were investigated and analyzed in our study.
Measurements KAP questions were designed by a ve-point Likert's scale (for the knowledge section: de nitely true, probably true, not sure, probably false, and de nitely false; for the attitude section: strongly agree, agree, neutral, disagree, and strongly disagree; for the practice section: always, often, sometimes, rare, and never). For the FP knowledge section, the score of each positive statement ranged from 1 to 5 for 'de nitely false', 'probably false', 'do not know', 'probably true' and 'de nitely true'. For the FP attitude section, the score of each positive statement ranged from 1 to 5 for 'strongly disagree', 'disagree', 'neutral', 'agree' and 'strongly agree'. For FP practice section, the score of each positive statement ranged from 1 to 5 for 'never', 'rarely', 'sometimes', 'often' and 'always'. The score was reversed for negative statements. The total score of FP knowledge, attitude and practice was the sum of score for questions for each section respectively.

Reliability and validity of the instrument
The content validity of the questionnaire was reviewed by three experts who had worked in the same eld in order to establish the relevance of the questionnaire items to the study aims. Each expert reviewed the questionnaire separately and some changes were made in the questionnaire based on their recommendations. The internal consistency was also measured to check the reliability. Cronbach's Alpha (α) values of the scale of FP knowledge, attitude, and practice suggested very good internal consistency reliability for the scales of this study. The alpha (α) value is good among knowledge-related 10 items (α = .84) and attitude-related 10 items (α = .89) and strong among practice-related 10 items (α = .95).

Data collection
The data collection started from 14th October and completed on 26th December 2019. Data were collected using a pretested, structured, and facilitator-administered questionnaire. The questions used in the questionnaire were prepared based on a review of the related literature. The survey was guided and conducted by ten female facilitators who have worked in the Rohingya camp for a long time and are quite familiar with the study setting. Ten Rohingya women from the survey area accompanied them to assist during data collection in the camp so that the study participants would feel comfortable talking with unknown people. Engaging the community members in conducting research is also suggested by Ahmed et al.
[18]. All of these recruited Rohingya women had experience in working with their community. The facilitators were quite familiar with the Rakhine/Arakanese language, which helped them explain the questions to the interviewee.

Statistical analysis
Descriptive statistics were used to see the overall percentage distribution of the study for respondents' FP-related KAP items. The variables with p < .05 in bivariate analyses (independent-samples t-test and Pearson correlations) were included in the linear regression models. Multicollinearity was also checked. The ANOVA values for overall FP knowledge (F = 64.84, p < .001), attitude (F = 59.56, p < .001), and practice (F = 170.36, p < .001) report that the regression model was a good predictor of the main outcome variables. All these analyses were performed with 95% con dence interval using SPSS 24.0. Variables with P < 0.05 were considered as statistically signi cant.

Results
Socio-demographic characteristics of Rohingya women Table 1 shows that of the respondents, 210 (52.4%) were from Buthidong sub-district and their mean age was 25.53 (± 6.34) years. More than half (51.8%) of them had no formal education and more than three-quarters (78%) were housewives. The mean amount of land the respondents owned in Myanmar was 5.27 (±6.22) acres. The average number of children of the study participants was almost 4 (3.98 ± 2.60). As to media use, 233 (58.2%) listened to the radio and 103 (25.8%) used the internet. According to the ndings, about one-third of refugee women reported that their husbands solely took decisions about their FP use, while more than two-thirds (68%) of respondents reported that they decided as to FP and other reproductive health in consultation with their husbands. Of them, 181 (45.3%) reported that NGO workers and health workers were the primary sources of FP information, while 154 (38.5%) said that physicians and nurses were their key informants about FP issues.   The Reasons for not adopting FP by Rohingya women Figure 1 displays the distribution of the causes for not adopting contraceptive measures by the respondents (N = 102) who were given the option for selecting multiple answers. Of them, 53 (51.96%) acknowledged that they were not using the family planning method due to their husbands' disapproval; 47 (46.08%) were not using it as they wanted to get pregnant; adopting FP method was considered as a cause for sin by 45 (44.12%); 29 (28.43%) thought that irregular sexual intercourse will not make them pregnant; 23 (22.55%) did not know how to use a contraceptive; 22 (22.57%) were worried about probable side effects; 17 (16.67%) did not want to use any; 11 (10.78%) believed that more children might bring nancial solvency in the family; and according to 7 (6.86%), contraceptive usage might reduce the pleasure of sexual intercourse.
Rohingya women's access to FP programs and services

Rohingya women's FP knowledge
Percentage distributions with a mean score of Rohingya women's FP knowledge-related items are reported in Table 3. Of them, 180 (45%) had accurate knowledge about the appropriate age of marriage for a girl. Of the respondents, only 162 (40.5%) answered correctly about whether taking a permanent contraceptive has any physical harm. Pertaining to the item 'using a contraceptive to have a negative effect on the husband-wife sexual relationship', 45.5% of the respondents had appropriate information. Moreover, 63% of Rohingya women responded correctly regarding the consequences of unintended or unplanned pregnancy. Relating to the item, 'a woman might have a risk if there is space less than 2 years between two births', 66.5% of respondents gave an a rmative reply.  thought that using FP might be a cause for sin, and slightly less than one-quarter (23.3%) believed that discussing FP with her husband might be a cause for sin. In addition, 272 (68%) had an opinion that one should not adopt FP if her husband objects. Of the respondents, 57% opined for bearing children until a male child is born and 40% of them would express happiness if a son is born. Regarding the item 'having more sons will ensure the security of the parents in elderly age', 50% of the Rohingya women were in agreement. Rohingya women's FP practice Table 5 shows that 43% of the respondents reported that they always felt ashamed to discuss FP and 45% were usually afraid of FP discussion with their husbands. In addition, about one-quarter always felt shy while discussing FP with relatives and neighbors. About three-quarters of Rohingya refugee women regularly used contraceptives during the study period. Furthermore, 60% of the respondents collect new contraceptive materials regularly after running out of them and 62% continued FP use despite its side effects. Linear regression analysis reporting factors associated with FP-related KAP with any health care provider (β = .24, t = 5.54, p < .001) were signi cantly associated with Rohingya women's high level of knowledge on FP and accounted for 66% of the variation in this regard.

Discussion
This study assessed the overall status of the knowledge, attitude, and practice regarding family planning among the Rohingya refugee women. We found that four-fths of the Rohingya refugee women have accurate knowledge of the bene t of using contraceptives and potential risks of This study found a positive correlation (r = .62, p < .001) between the age of Rohingya women and the number of children. This implies that the Rohingya women will be likely to have more children as they have a minimum fertile period of 15 years. About 50% of women aged beyond 30 had six or more children. Despite having 5-6 children, the Rohingya women desire even more children. In addition, most of those who want to have more children want a son.
We also explored whether the respondents had ever heard about contraceptive methods and whether they were currently using any, which showed that 90% of the women did not know some contraceptive methods such as IUD and Norplant, although they knew about contraceptive injections, oral pills, and condom, which were the common methods provided now. But the local media reports that the Rohingya refugee women were initially given oral pills but they would take them home and throw them away. Later, they were brought under the three-month injection method, and most of them have adopted it. Although contraceptive methods have been introduced among the Rohingyas who have taken shelter in Bangladesh since the 1990s, this activity has increased in recent times after the massive in ux of Rohingyas. Indeed, NGOs do not disseminate the information of different modern birth control methods among the Rohingya women as they are reluctant to use them [1,19,20].
According to the study results, one-third of the respondents said that their husbands make the decisions about their wives' health. Two-thirds replied that both husband and wife make decisions together. The majority of males have no interest in using condoms as they cannot provide complete sexual grati cation. However, 3% of men adopted condoms because their wives had a side effect participation in a FP awareness program or severe complications after using a female-usable contraceptive method. The condom is also used by those who are a bit educated and have worked with NGOs.
Our ndings also showed that there was a dearth of in-depth knowledge of family planning among the Rohingya women living in the refugee camp of Cox's Bazar even though they have some rudimentary ideas about small family norms and using contraceptives. There are a deep-rooted skepticism and some misunderstandings among the Rohingya regarding contraceptive methods. The literature reveals that contraception methods were accessible in Myanmar but most of the Rohingya were reluctant to use contraception due to fears of permanent sterility and other morbidities [2,4]. Even for women, who have reported being willing to pursue family planning approaches, discontinuation may be motivated by the general climate of uncertainty and fear, particularly about health-related side effects [2]. Indeed, among the Rohingya women, religious conservatism and shyness are very common. Some women are ashamed to nd about the details of family planning or contraceptive methods and some are not interested in knowing the details because of religious reasons [19]. Away from the light of education, this group is steeped in religious orthodoxy.
To them, children are a gift from God; therefore, it is a great sin to prevent them from coming into the world [19].
Half of the respondents lack proper knowledge of whether a girl is eligible for marriage before the age of 18. Among the Rohingyas, girls are likely to get married at an early age. A previous study [2] noted a clear preference for girls but not boys on child marriages. There are some reasons behind the girls' early marriage in the Rohingya society. Firstly, this tendency is more prevalent in families where there are more daughters because they feel that more than one daughter still living with parents is a burden, and they want all their daughters to get married while they are still alive. Secondly, members of the community also say different types of harsh words and pass nasty comments if more than one young girl live with them, so, the parents want to marry their daughters off as early as possible. Thirdly, this is related to their faith. Girls are deemed suitable for marriage until they hit puberty. Parents believe that keeping young girls unmarried at home for too long a time is a sin. Fourthly, the Rohingya people are not nancially solvent and that is why they want to send their daughters to the in-laws' house so that they do not have to bear the cost of their living with them for a long time. A qualitative study by Ainul et al. [2] identi ed some important shifts in the trends and behaviors of marriage after displacement. Unlike in Myanmar, the camps have no age limit on the wedding. So, Rohingya girls and boys tie the knot as early as the age of 14/15 years.
Rohingya women have also shown more interest in having more children. Lagging in their education, they still see childbirth as an achievement [21]. In our study, for example, only 40% opined that two children are enough for a couple. Half of the respondents think having more children will give them more protection and support in their old age. They think that the child is a God-gifted blessing; they will receive more rewards if there are more children. Getting food cards is also a factor here since it is available for every child [22]. By showing that card, parents get various bene ts, including food, medicine, and clothes. They know that they will get more food cards or help if they have more children [23]. Many of the children's food items they get with food cards are sold outside the camp for cash. We too found this out at the Teknaf bus station: the food items provided by the UN were being sold openly among the host community. Some NGOs also encourage the Rohingya mothers to have more children by allocating them a small amount of money and giving food cards. As a result, Rohingya families do not use contraceptives although they are urged by the government to adopt FP. Another reason for Rohingya people to have more children may be explained by their thinking of Myanmar government's oppression to eradicate them ethnically. Having more children can also be an attempt to sustain their existence as a nation. Our assumption is also supported by media reports [23].
Our study ndings also show that more than two-thirds of the Rohingya women think that family planning methods should not be used without the husband's permission. In Rohingya society, patriarchy prevails and women mostly do obey their husbands. They regard it as a sin to do anything against the wishes of their husband. Many husbands are reluctant to allow contraceptive use to their wives [24]. In addition, according to our ndings, 58% of respondents said that they should continue childbearing the birth of a son. Besides, 40% of the respondents said that having borne a son is a matter of pride, while one-fth considered daughters as a burden. Parents too have a similar feeling as marrying a daughter costs a lot, and daughters cannot take their parent's responsibility in the future. On the contrary, they have high expectations for a male child and think that the boy will earn money and bear parents' responsibilities later.
Our data also shows that more than 40% are ashamed of and afraid of discussing FP with their husbands, considering it as a sin. In Rohingya society, topics such as FP or birth control are perceived as a high-level taboo. Rohingya women are usually very conservative due to the prevailing religious and social values. Socially, there is no positive viewpoint regarding FP or birth control, and religiously it is considered a sin. Those who have not yet adopted FP and are not interested in adopting it in the future are the extreme opponents. The women forming what is called the hardcore resister group by Rogers [25] are more religious and their husbands are older religious leaders. They need to be brought under FP through a strategic communication program. Otherwise, this radical opposition group has a higher likelihood of making a signi cant contribution to population growth in the refugee camps.
The knowledge and behavior of the women from Rachidong area are better than those of the Rohingya women from Maungdaw and Buthidong area as the communication system in Rachidong is much improved and Rachidong people have more opportunities of commuting to the city to study and interact with the people there.
According to the results, Rohingya women involved in various professions have a better KAP of FP. They normally work with various NGOs as the animator/teacher for providing education and psychosocial support, community mobilization for nutritional activities, cleaners, or as day laborers.
NGOs offer different types of training and awareness sessions for them, so their attitude and behavior are positive. They are also interested in knowing about new things and they have a better chance to interact with the Bangladeshi staff more closely.
Women with fewer children were found to have better FP-KAP in our study. This cohort is more conscious and progressive than others as they engage and remain focused actively in various awareness sessions. Consequently, they become the primary and early receptive of FP services. Family members, in particular husbands and mothers-in-law, play a key role in making decisions about a married girl's childbearing and contraceptive options in the Rohingya society [2]. Nevertheless, the Rohingya women who can make their own decisions about their health have better FP-KAP. Generally, these women are aware and self-reliant. They also have a better attitude and perspective since their husbands and families allow their views to be expressed independently.
We observed that the Rohingya women who learned from doctors and nurses had better FP-KAP. In this case, all these women's interest plays a big role in listening carefully to the information provided by health care providers and applying it in real life. Health care providers have been able to talk to them, change their attitudes and make them more positive. According to the Department of Family Planning, in addition to raising awareness and birth control attitude among Rohingya men and women in the camps, doctors and nurses also provide various suggestions and medicines on pregnancy, maternity, child health, and general health services which appear to be more signi cant than that of NGO health workers.
The bene ts of these activities are being reaped. Many Rohingya couples now do not want to have 10-12 children; instead, they want to limit the number of children to 4-5 (DBC News, 2019). Most of these programs and services have created a positive outlook on FP that makes women and girls now more conscious than before [19].
Rohingya women who have visited a clinic and talked to a doctor have good FP-KAP. Doctors and nurses play a supporting role in making them understand FP. Nevertheless, in most cases, Rohingya women do not want to go to the clinic, or even if they do, they are not interested in hearing about FP. Those who are somewhat educated and aware visit the clinic to know about FP. Through visiting a clinic, they can observe the poster and other communication materials and be informed about different aspects of FP and maternal health issues.
There are some limitations. Firstly, the data from the participants may have been affected by social desirability, which could affect the validity of the outcome. Secondly, this analysis could not provide a more precise understanding and a more in-depth insight into the matter as no method of gathering qualitative data was used. Thirdly, the di culties were even more marked because of the distances among different blocks where simultaneous data collection was going on. The data was collected from one camp due to a lack of adequate funds.

Conclusions
The study shows that the comprehensive FP-KAP capability of Rohingya refugee women is low. Contraceptives among the Rohingyas are unpopular, mainly due to a lack of education and family planning awareness. In addition, family planning initiatives among Rohingya refugees were limited by some traditional cultural and religious beliefs. Participation in a FP program, visiting a health facility, and talking with the health care provider were reported as the most signi cant predictors for a better FP-KAP. Therefore, designing appropriate campaigns and developing effective communication materials is important to improve this vulnerable community's maternal health status. Accordingly, politicians, program managers, and implementers should educate and equip Rohingya women on essential FP, reproductive and sexual health, and maternal healthrelated topics through a sustainable and continuous training program to increase their knowledge. Moreover, the program should also involve religious leaders in planning and implementation and provide them with appropriate training so that they too can play a supportive role as opinion leaders. Rohingya women's access to FP and RH services