Intention to use long acting contraceptive methods and associated factors among women currently using short acting contraceptive methods in Gondar city, northwest Ethiopia: using the theory of planned behavior.

Objective Despite its effectiveness, the intention and utilization of long acting contraceptive methods is very low in many developing countries and the use of long acting contraceptive methods has not kept in pace with that of short-acting methods such as, oral contraceptives and injectables. Result The magnitude of intention to use long acting contraceptive methods was 39.8%. Intention to use long acting contraceptive methods was higher for women whose husbands were farmers when compared to women whose husbands were government employees (β = 0.49, 95% CI: 0.41, 0.72). Number of children wanted (β = − 0.19, 95%CI: -0.28, -0.1), attitude (β = 0.34, CI: 0.23, 0.46), subjective norm (β = 19, 95%CI: 0.12, 0.27) and perceived behavioral control (β = 0.18, 95%CI: 0.06, 0.3) were factors signicantly associated with intention to use long acting contraceptive methods. Intention to use long acting contraceptive methods was low. Interventions that focus on women’s attitude towards long acting contraceptive methods and support group, peer education, social mobilization and persuasive communication could promote intention to use long acting contraceptive methods.


Introduction
Family planning can prevent at least 25 percent of all maternal deaths by allowing women to delay motherhood, prevent unintended pregnancies, and avoid unsafe abortions. It also protects women from sexually transmitted infections, including HIV/AIDS [1].
In many sub-Saharan African countries, long acting contraceptive methods practice have lowest rates and is sometimes missing component of national family planning programs [2]. For example, in Kenya, the contraceptive prevalence rate (CPR) increased from 17% in 1984 to 19% in 2003. Despite its increase, a decreasing proportion (from 31-2%) of Intra Uterine Device (IUD) use in the national method mix had been documented. Also in Guatemala even if contraceptive prevalence rate increased ,decreasing proportion of IUD use in the method mix had been reported [3].
In Ethiopia, the contraceptive prevalence rate at national level has quadrupled from 6% in 2000 to 27% in 2011. But as most sub-Saharan African countries like Malawi and Rwanda, diversifying the method mix is still a big challenge. Injectables predominate, accounting for 76% of modern method use [4], where as long acting contraceptive methods (LACMs) contribute only 4.2%. Implant 3.4%, intrauterine device (IUD) 0.3%. Unmet need for family planning is 25% and 22% for Ethiopia and Amhara Regional State, respectively [1].
Over long term, LARC methods are 20 times more effective than short term contraceptives [5].If only one of ve sub-Saharan African women now using pills or injectables were to switch to an implant, more than 1.8 million unintended pregnancies would be averted in 5 years, resulting in almost 600,000 fewer abortions and 10,000 fewer maternal deaths [6].
Currently, the Ministry of Health (MoH) has been giving due attention for expansion of LACMs. To achieve this goal, MoH has practiced the task shift, which enabled the Health Extension Workers to provide Implant at community level and the scale-up of Intrauterine Contraceptive Devices was initiated in more than 100 district hospitals and permanent contraceptive method at selected health centers and hospitals [7]. However, the contraceptive prevalence rate is still highly dependent on short-term family planning methods with low utilization of LACMs and unmet need for family planning is still high for spacing births (16%) and limiting (9%) [1].
Since intention is the best predictor of behavior (utilization of LACMs), this study assessed the intention to use long acting contraceptive methods and identify factors affecting it among short acting contraceptive users using the theory of planned behavior. Results from this study will help in developing evidence based LACMS health promotion programs.

Study design and period
Institution based cross sectional study was conducted from March to April, 2017.
Sample size and Sampling procedure Sample size was determined by single population proportion formula using EPI INFO stat calc program with the assumption of population size 154,767, 95% level of con dence, 4% of marginal error, and taking proportion of intention to use long acting contraceptives, Implants 71.3%, IUCD 24.0% [23]. Considering 5 % non-response rate, the nal sample size became 519. The study participants were selected by using systematic random sampling technique and the sampling interval was 2.

Data collection instruments and procedures
Data were collected using a pre-tested, structured questionnaire having two parts. In the rst section information about socio-demographic, economic and reproductive history was collected. In the second section, the theoretical constructs were measured. The number of questions for each construct varied between three and ten. Forty-four items of Theory of Planned Behavior (TPB) constructs were assessed on a 5-point Likert scale and they were scored into respective constructs for analysis. Since most women are not familiar with the phrase, long acting contraceptive methods, it was de ned in the questioner as long acting contraceptive methods are methods that are used for three and above three years, IUCD and implant. The questionnaire was initially prepared in English and translated in to Amharic (the o cial language uently spoken by all participants) and again translated back to English to check for any inconsistencies or distortions in the meaning of words and concepts. The reliability of the tool was checked using Cronbach's alpha reliability test with a score of 0.82 (95% CI 0.801-0.837).

Operational de nitions:
Intention: Intent to use IUCD or implant within one year.
Attitude: The women's overall evaluation of the bene ts and risk of long acting contraceptives.
Subjective norm: Women own assessment of the social pressure to use or not to use long acting contraceptive and her motivation to comply. Short term contraceptives: Pills and depo provera injection that are taken on a daily basis and every three months.

Results
Demographic, socioeconomic characteristics information of the Participants A total of 519 women of short-acting contraceptive users participated in this study with 99.2% response rate. The respondents' age ranged from 15 -48 years with the mean age of 26.77 (SD±6.1) years. One hundred sixty-two (31.5%) participants were in the age category of 25 -29. From the study participants 453 (88%) were married. Majority of the women 468 (90.9%) were Orthodox Christians and 478 (92.8%) women were Amhara by ethnicity.
Concerning educational status, 167 (32.4%) of the respondents were unable to read and write at all and 124(27.4%) of their husbands were unable to read and write. Regarding occupation of the respondents 250 (48.5%) were housewives. The median monthly income of the respondents was $74 (Table 1). With regard to subjective norm, about 214 (41.6%) of the women answered that most people who are important to them think that they should not use LACMs. Two hundred twenty-three (43.3%) of the respondents disagreed that most people whose opinions they valued would approve of their using LACMs.
Concerning perceived behavioral control, about 262 (50.9%) of the respondents replied that it is di cult for them to use LACMs and 132 (29.7%) of them answered that it is easy for them to use it. Two hundred ninety-four (57.1%) of the women were con dent that if they wanted to, they could use LACMs within one year. Nearly 360(69.9%) of the women answered that it is possible to use LACMs (Table 2). For women whose husbands were farmers, the score of intention to use LACMs increased by 0.43 when compared to women whose husbands were government employees (β =0.49, 95% CI: 0.41, 0.72). For every unit increase in number of children wanted in the future, the score of intention to use LACMs decreased by 0.19 (β =-0.19, 95%CI: -0.28, -0.1) ( Table 3).

Discussion
The overall magnitude of intention to use LACMs within one year was 39.8% (95%CI: 35.7, 44.3). This result was in line with the study done in Wolaita which was 38% [20]. But it was slightly lower than the study done in Adigrat which was 48.6% [8]. The difference could be due to disparities in the study settings and myths and misconceptions on long acting contraceptive methods.
In this study attitude, subjective norm, and PBC were statistically signi cant factors of intention to use long acting contraceptive methods. These results support Ajzen's theoretical assumptions [23]. The more women have positive attitude, believe that people around them would approve of their actions and believe that they have a high degree of control over using IUCD and implant, the greater will be their intention to use LACMS.
Attitude plays the most important role in predicting women's intention to use LACMs. For each unit increase in score of attitudes, score of intention to use LACMs increased by 0.34. Also the study in Wolaita, Ethiopia documented that those women who had positive attitude had higher intention to use LACMs than women who had negative attitude [20]. Most of the women thought using these methods would subject them to different problem and they thought it wouldn't allow them to effectively carryout their daily activities hence in fear of the perceived side effects they didn't intend to use LACMs. A unit increase in score of perceived behavioral control decreased the score of intention by 0.18. Three hundred twenty-two (62.5%) of the respondents agreed that if they wanted to use, they could use LACMs.
This means that if they wanted to use LACMs, there was no barrier that could stop them from using LACMs. But 302(58.7%) of the women agreed using LACMs was di cult for them. This might be due to fear of pain during insertion of implant or IUCD.
Number of children wanted was also signi cant (β = − 0.19, 95%CI: -0.28, -0.1). As number of children wanted increase by a unit, the score of intention to use LACMs decreased by 0.19. This nding was supported by the study done in Adigrat [8]. If they had a plan to conceive soon, they preferred short acting contraceptive methods. It might also be due to fear of side effects and the misconceptions that LACMs could harm the womb and cause infertility after the use of LACMs.

Conclusion
Intention to use LACMs was low. Attitude, subjective norm, perceived behavioral control, number of children wanted in the future, and husbands' occupations were factors signi cantly associated with intention to use LACMs. Therefore, Programs aimed at increasing LACMs utilization need to address these identi ed factors of LACMS against users of short acting contraceptive methods.

Limitation Of The Study
Social desirability bias was the limitation of the study because respondents perceived intending to use LACMs is expected of them. Therefore, there is some potential for reporting bias which may have occurred because of the respondents' interpretation of the questions or desire to report their emotions in a certain way or simply because of inaccuracies of responses. Gondar. All methods were performed in accordance with the relevant guidelines and regulations. Permission to conduct the research was obtained from Gondar city administration. Written Informed consent was obtained from respondents who were selected to participate in the study after explaining the purpose of the study and consent was obtained from the parents of minor study participants (15 years old).