Impact of Exposure to Mass Media on Utilization Modern Contraceptive Among Adolescent Married Women in Ethiopia: Evidence from EDHS 2016.

Methods This study conducted based on Ethiopia demographic and health survey 2016 data which was cross-sectional study design. EDHS adolescent married women sample size used was 588. The data were analyzed using propensity score matching and recursive biprobit probit model to determine impact and factor associated with mass media exposure on modern contraceptive utilization. 17% and more likely than In this study factor index, exposed


Introduction
More than one billion of world population was adolescent age group. Adolescent are high risk of unwanted pregnancy related to pregnancy is preventable. This complication can be preventing by use of family planning method. One of the challenges to use family planning was lack of information about contraceptive.

Objective
The objective of this study was to assess the impact of mass media on use of modern contraceptive among adolescent in Ethiopia, 2016 E.C.

Methods
This study conducted based on Ethiopia demographic and health survey 2016 data which was crosssectional study design. EDHS adolescent married women sample size used was 588. The data were analyzed using propensity score matching and recursive biprobit probit model to determine impact and factor associated with mass media exposure on modern contraceptive utilization.

Result
The magnitude of modern contraceptive utilization among adolescent married women age group 15-19 years was 31.8 %. Expose to family planning message has 16.8%, 13.2%, 17% and 21.9% more likely to use modern contraceptive than unexposed to mass media message. In this study signi cant factor affect modern contraceptive use include exposure to mass media message family planning, residence, wealth index, exposed to TV message, radio message and magazine message.

Conclusions
This study shows magnitude of contraceptive utilization was low and it might be due to lack of information about family planning. Therefore policy maker and concerned body should consider mass media to integrate family planning program.

Background
Adolescents age between 15-19 years comprise about one-sixth of all women of reproductive age globally. Adolescent estimated about 250 million live in developing countries. More than one in ve of adolescent girls are currently married. Every year 16 million women aged 15-19 years give birth and 95% of these births take place in developing country (1). Child birth among adolescent face higher risks of maternal mortality obstructed labor, obstetric stula, and low education attainment and unemployment (2).
Modern contraceptive is important to prevent unintended pregnancies and reducing the high adolescent birth rates in developing country (3,4). Married adolescent women want to delay space or limit their births but many of adolescent not using contraceptive. Helping adolescent girls to use contraceptive would avoid unintended pregnancies that can have bene t life long that can have far-reaching bene ts for them, their children and societies as a whole (5,6).
Family planning encompasses the services, policies, information, attitudes, practices, and commodities, including contraceptives (4).Adolescent girls has long been neglected in the global health agenda but this period is pivotal for promoting heath behavior that could have lasting impact on their future health and wellbeing (7).
The source of information and advice about how where to access of modern contraceptive and is important for adolescent that contributed by mass media. Mass media important in health promotion and disease prevention is well documented, since both routine exposure to and strategic use of mass media play a signi cant role in promoting awareness, increasing knowledge and changing health behaviors (8)(9)(10). Mass media create public awareness about family planning including knowledge, effectiveness and source about contraceptive methods (11). It was important components of information education and communication that can be effective to promote family planning programmes (12) Mass media channels include such as radio, television and newspapers are important sources of information about contraceptive information. Radio is the major source of information in sub-Saharan Africa (76%), print materials (72%), television (62%), and outreach workers (52%). In this region there is increase of available of these mass media. In sub-Saharan Africa, 5.2% of all households now have a television and 36.9% of the population subscribes to mobile services (13).
Inadequate knowledge and perception regarding a disease is a major drawback to prevention and intervention of any public health challenge; this can be addressed greatly by strengthening health communication tools and disseminating health information through the conventional and/or digital media (14,15). Media can play an important role in changing sexual behaviors, transforming negative beliefs and increasing family planning knowledge(9).
Yong people have indicated the media as a top source of information that young people are excessive users of media including Television, radio, and newspapers, are widely used to reach a large proportion of population but mass media focused on members of the general public, or more narrowly on youth (13,16). Exposure to such messages about family planning is generally passive, resulting from an incidental effect of routine use of media. The great promise of mass media campaigns lies in their ability to disseminate well-de ned behaviorally-focused messages to large audiences repeatedly, over time and at a low cost per head (17).
Mass media is particularly potent as it allows national and local program planners to reach a large proportion of an intended population within a relatively short time. Mass media is credible that have generally aimed primarily to change knowledge, awareness and attitudes, contributing to the goal of changing behavior (8,18).
This study assessed the prevalence and effect of exposure to mass media on contraceptive behaviors. It will examine whether observed differences in the levels of modem contraceptive use signi ed a positive relationship between exposure to family planning messages and use. General, this evidence provides justi cation for recommending that these types of interventions be implemented more widely in future.

Study design
Ethiopia demographic health survey (EDHS) 2016 was cross-sectional study design and used multistage sampling technique. It includes all regions and two administrative cities. EDHS study period from January 18, 2016 to June 27, 2016 (19).

Study area
Ethiopia was study area since EDHS was national representative data. Ethiopia located in at horn of Africa. Ethiopia second most populous country most that estimated about 108,805,142 in 2018 (20) . (21). In country 24% of population constitute reproductive ages constitute and family planning service provide 24hour.

Data source and extraction
The data for this analysis were extracted from the 2016 Ethiopian Demographic and Health Survey (EDHS). The data sets were downloaded in STATA format with permission from the Measure DHS website (http://www.dhs program.com). After understanding the detailed data sets, further data cleaning and recording were carried out. Required data sets were joined to Global Positioning System (GPS) coordinates of EDHS.

Sample size determination and sampling procedures
Ethiopia demographic and health survey 2016 collect 588 adolescent married women (weighted sample) age between 15-19 years (19). Strati ed and two-stage sampling technique was used. In rst stage primary sampling unit selected and in second stage household was selected with different probability of selection. (19).
Data management, data processing and analysis methods Data was downloaded from measure DHS website in STATA format. Data management and cleaning was done using STATA. All needed variable was selected and recoded in convenient way. After managing adolescent related data, sampling weight was employed to produce the proper representation of family planning information in analysis of data. STATA 14 used for data extraction, descriptive and summary statistics and impact assessment model. The descriptive statistics report summarizes data and respondent characteristics while inferential data analysis using chi square tests report relationship of characteristic. Impact of mass media exposure on modern contraceptive utilization is analyzed by propensity score matching and recursive biprobit probit model regression.

Impact assessment
We use PSM and recursive biprobit probit model to asses impact (22,23). Recursive biprobit probit model was used for addressing the issue of endogeneity (24).

Propensity Score Matching
Treatment effect refers to the causal effect of a given treatment or intervention on an outcome variable of interest. Treatment effect is de ned for each individual unit in terms of two "potential outcomes." Mass media is treatment variable and modern contraceptive (Y1) the potential outcome or no modern contraceptive (Y0) counterfactual for that subject. Those expose to mass media would observe Y1, so Y0 would be the counterfactual outcome for that subject. The "treatment effect" is the difference between these two potential outcomes. However, this individual-level treatment effect is unobservable because individual units can only receive the treatment or the control, but not both.
Propensity score matching clarify the effects of campaigns on contraceptive use. Propensity score matching allows the researcher to "create" an unexposed, matched control group that is statistically equivalent. The main attribute of the matching procedure is the creation of the conditions of randomized experiment in order to evaluate a causal effect as in a controlled experiment (25)(26)(27).
The impact of mass media on modern contraceptive utilization is estimated using the endogenous regression model where model can be used to compare observed and counterfactual mass media. PSM estimated in Stata using command psmatch2. The psmatch2 implements full Mahalanobis matching and a variety of propensity score matching methods to adjust for pre-treatment observable differences between a groups of treated and a group of untreated. It used to estimate ATT, ATU and ATE (28)(29)(30).

Recursive Bivariate Probit
Recursive Bivariate Probit (RBP) process the resulting Bivariate Probit correlation parameter as a recursive model of simultaneous equations. It is important because of handling of endogenous binary repressor on two binary outcome variables. It also estimates maximum-likelihood two-equation probit models by allow to two binary outcome variables correlated with each other. The bivariate probit model is frequently used to determine factor, impact and test endogenous of treatment variable (24,31).
The exogeneity of exposure to mass media family planning message is test in recursive bivariate probit model by . The Wald test, which is re ected by statistical signi cance of was used to determine whether the models would be best estimated jointly in a recursive manner of not. Likelihood-ratio test is available after bivariate probit to detect the presence of endogeneity and rule out using a simple single-stage binary probit (32,33).

Outcome variable
The outcome variable modern contraceptive recorded in measured DHS as modern method, traditional and no method. It categorize as "modern method" and "no modern method". Traditional method user consider as none modern method user. It classi ed as "yes" (coded as 1) and "no" (no coded as 0).

Explanatory variables
The predictor variable for modern contraceptive utilization was taken from previous studies. It consider as control variable to determine effect of mass media. Variable include in study were education, wealth quintile , respondent religion, living children, partner education(coded as no education, educated ) ,working status of respondent , desire more children , visit to health facility and exposed to mass media by radio, TV and magazine message .

Endogenous treatment variable
Mass media exposure to family planning message is considers as treatment variable. It was generated by aggregating family planning message exposed to one of media television, radio and magazine (coded as yes and no).

Ethical consideration
After request EDHS Program for dataset, permission was granted to download and use the data for this study and data were used solely for the purpose of the current study. The consent was obtained from participant before study. Individual identi cation was not used to treat data con dential. Further the study approved by institutional ethical review board of Dessie Health Science Collage (IRB), Ethiopia.

Patient and public involvement (PPI)
Since the analysis was based on secondary analysis of EDHS 2016 there was no Patient and public involvement (PPI). But during data collection by measure DHS PPI participation was considered.

Results
Description of Scio-demographic and mass media coverage among adolescent In EDHS 2016, a total of 588 adolescent married women were interviewed. The mean age of the respondents was 17 years (SD ± years). One third of the respondent 171(29.07 %) has no formal education. Most of respondent 526(89.48) were resident in rural area. About 272 (46.43%) of respondents had more than two children. Mass media accessibility among married adolescent in Ethiopia DHS were radio and television 147(24.95) and 33(5.67) respectively. About 147(25) of respondent own mobile phone but most of respondent not use internet in 12 last month. Regarding to mass media exposure, about 181 (30.88%) of respondent frequently listen radio message, 119(20.25%) of respondent frequently watch TV message and 71(12.11%) of respondent frequently read magazine message (Table 1).
Exposure to mass media family planning message among married adolescent Exposure to family planning message among modern contraceptive use and intention to use for future were assessed by chi square test. Modern contraceptive utilization is associated with exposure to mass media message. Contraceptive behavior like intention to use for future and knowledge about family planning message also associated with mass media exposure ( Table 2).

Impact of Mass media exposure on modern contraceptive utilization
Propensity score matching analysis Treatment effect estimation based on psmatch2 estimation has output before matching and after matching. Unmatched estimate show difference between average utilization modern contraceptive among mass media exposed and unexposed respondent before matching is arranged. After matching average treatment effect for the treated (ATT), average treatment effect for the controlled (ATU) and average treatment effect for the population (ATE) on utilization of modern contraceptive utilization and intention to use for future is reported ( gure1). As a result those exposed to mass media family panning message had 16 % and 18 % more likely to utilize modern contraceptive and intention to use for future ( Table 3).

Determinant of mass media exposure, and contraceptive use
In this study both univariate probit and recursive bivariate probit model was used to estimate determinant of modern contraceptive use. Recursive bivariate probit model was better explaining the relationship than univariate probit model. The results of the recursive bivariate show exposure to mass media message increases the probability of modern contraceptive utilization. Modern contraceptive utilization is signi cantly affected by mass media exposure to family panning message, richest wealth index and residence positively. But respondent no educated were negatively affect modern contraceptive utilization. Exposure to mass media message about family planning is signi cantly affect by presence of TV in household, exposé to TV message, expose to radio message , expose to magazine message, internet user and visit heath facility (Table 4).
Similarly for intention to use recursive bivariate probit model better explain model. Recursive bivariate probit model was better explaining the relationship. Those respondents exposed to family planning message and partner education positively affect intention to use modern contraceptive use (Table 5). Over all, the univariant probit model is insigni cant in both outcome but recursive bivariate probit is signi cant to explain the outcome. Because of endogenous factor it exhibit different output so we used recursive bivariate probit to explain the relationship between exposed to family planning message and both outcome.

Discussion
This study assessed the in uence of mass media exposure about family planning message on contraceptive behavior based on national representative data of EDHS 2016. Mass media can be used promoting family planning program successfully.
Exposure to family panning message is low among adolescent married women. This is due to low accessibility of radio, TV, mobile and internet access. Exposure to family panning message is with associated with modern contraceptive utilization and the intention to use. This indicates that the accessibility of mass media is important to disseminate knowledge and attitude about of family planning program (9,34).
The impact of exposure to mass media on modern contraceptive use and intention to use for future is assessed by using propensity score matching using four matching estimator after balancing of propensity score. Expose to family planning message has 16.8% and 14.2% more likely to use modern contraceptive and plan to use contraceptive for future by using KM.
The predictor of exposure to family planning message and modern contraceptive asses by recursive biprobit model since univariate probit model is insigni cant to explain the relationship. Recursive biprobit model result shows mass media exposure increase use and intention to use modern contraceptive among married adolescent. Factor associated with modern contraceptive utilization were exposure to mass media family planning message, residence, wealth index and educational level. In other side factor associated with intention to use for future include exposure to mass media family planning message, residence, educational level and partner educational level. Expose to mass media message about family planning and determinate for both utilization of modern contraceptive and intention to use for future by controlling covariant. It was support by different previous research (35,36).
Educational level, household wealth index and place of residence signi cantly associted with utilization of modern contraceptive and it support by different study (37,38). Signi cant factor associated with exposure to family planning message include presence of radio in household, presence of TV in household, use of internet, health facility visit, frequently listing radio, frequently watching TV and frequently read magazine.
Frequently watching TV was strongly associated with exposure to family panning message. It increases the probability of hearing family planning message even more power full than other media. It was supported by other stud Nigeria (18) and Central Asia (39) .The possible explanation may be television is a powerful medium for appealing to mass audiences and reaches people regardless of age, sex, income or educational level. In addition, television offers sight and sound and makes dramatic and lifelike presentations of people and products. We mostly believe what we see rather than what we hear (36).
Frequently watching radio is second most important type of mass media that had strong relationship with exposure to family planning message. Previous studies indicate that radio was low cost to access and reach to mass audience. Radio is less e cient than television in transmitting message it might be because of TV has visual image. Radio can increase public health messages about family planning in detail (39,40). Frequency of listening to radio amongst married women in this study was lower than other developing countries (35).
Frequently read magazine signi cantly associated with family planning use especially it give detail health reporting that not feasible with other media. It was detail, exibility that can be read frequently and share to other (35).
Frequent use internet increase exposure to family planning message. The reason may be use of internet might retrieve information about family planning based on their interest.

Conclusion
This study assesses the impact of mass media exposure about family planning message on modern contraceptive use and intention to use. It showed exposure to mass media family planning message affect both utilization of modern contraceptive and intention to use for future.
This study suggests low prevalence of contraceptive utilization associated with lack of information about family planning. Since adolescent was under in uence of partner and community to give appropriate information about family planning mass media has advantage. Therefore policy maker and concerned body should consider mass media to integrate family planning program.

Strength and limitation
Strength include Demographic Health Survey is national representative data that used multistate sampling technique.
The DHS data was collected with international standard and trained data collectors. The data quality was assessed in different stage of data collection and entry process.
Limitation include that DHS is nonrandomized data and not include all variable needed for analysis of this study. As result of data were collected for survey the variable may not include nor needs some efforts to select the variable of interest. DHS dataset not include or incomplete of some of the variables focusing on mass media and family planning were incomplete or not lled as the will of the investigator. Ethics approval and consent to participate Informed consent was taken from the participant prior to study by measure DHS. Ethical approval obtains from DHS measure International Program which authorized the data-sets and GPS coordinate les upon request. The study further approve by Dessie health Science College after submitting proposal to IRB and it approved with ID number of 0525/12.

Consent to Publication
Not applicable

Availability of data and materials
The data is available from DHS program. All relevant data are included in the manuscript. However, the minimal data underlying all the ndings in the manuscript will be available upon request. The data was taken from DHS website (http://www.dhs program.com). The data would be accessed by contact with correspondent author.