Determinants of intention to use family planning methods in the four emerging regions of Ethiopia: an ideation score based assessment

Ethiopia has recorded significant progress in improving its population’s access to family planning (FP). According to the Ethiopian demographic health surveys (EDHS), contraceptive prevalence rate (CPR) has increased from 8% in 2000 to 36% in 2016, a fivefold increase [1‐4]. At the same time, unmet need, meaning the proportion of fecund women who are not using contraception but who wish to postpone their next birth or stop childbearing altogether, decreased from 37% in the 2000 EDHS to 22% in 2016 [1‐4]. Knowledge about FP methods is near universal, with 98.3% of women surveyed able to identify at least one modern contraceptive method [4]. The country has also massively expanded health care facilities and the Federal Ministry of Health (FMoH) estimated that 90% of the population had access to health care in 2011 [5]. The most recent service provision survey estimated that 87% of health facilities (excluding health posts) offered modern family planning methods [6].

Ethiopia set ambitious targets for the year 2020 to increase the CPR to 55%, reduce the total fertility rate from 4.1 in 2018 to 3, and decrease the unmet need for FP to 10% [7]. Despite overall progress in decreasing in the unmet need for FP, there is substantial inequality in FP access across population groups due to socioeconomic, education and place of residence factors [7]. There are also sizeable cross-regional differences in contraceptive use, and little or no progress in expanding access to FP services in the four emerging regions (Afar, Benishangul-Gumuz, Gambela, and Somali) has been observed over the past years [1‐4]. Afar and Somali in particular lag behind national contraceptive prevalence with rates of modern contraceptive use of 12% and 1%, respectively. Contraceptive prevalence in Benishangul-Gumuz (28%) and Gambela (35%) is closer to the national average [4]. Reasons for the disparity and psychosocial factors that expect to affecting uptake of contraceptives are not clearly identified in Ethiopia’s emerging regions.

Globally, factors beyond access to family planning and health services have been shown to affect rates of contraceptive use. These factors may include socioeconomic and cultural determinants, household factors such as partner’s attitude and support, and individual determinants including knowledge and attitudes toward FP.

Ideation provides a lens through which these individual level factors may be explored. Ideation is the concept that people’s actions are influenced strongly by their beliefs, ideas, and feelings (‘‘ideational factors’’); it provides a framework to understand behaviors, including contraceptive behavior [8]. Some studies have posited ideational change to be a key factor in the second demographic transition in Europe [9, 10] and in recent fertility declines in some less industrialized countries [11]. Ideation models have been used among demographers and public health experts to better understand how the individual psychosocial factors may influence family planning use and contraceptive uptake [8, 12‐15]. The ideation model conceptualizes and structures the psychosocial factors of behavior, thus enabling a greater understanding of the multiple factors that determine family planning behaviors.

This study used Kincaid’s modified version of ideation model, which links individual ideation with behavior, and the Ideation Model of Strategic Communication with Behavioral Change [16]. This model comprises three domains: cognitive, emotional, and elements of social interactions. The cognitive dimension includes the following psychosocial concepts: attitudes, knowledge, perceived risk, subjective norms, and self-image. The emotional domain includes preferences and self-efficacy. Finally, the social elements of ideation include social support; social influence; interpersonal communication (e.g., spousal communication); and personal advocacy [16‐18].

In this paper, using a modified ideation model, we aimed to identify ideational factors that influence intention to use FP methods among married and unmarried women of reproductive age (WRA) in the four emerging regions of Ethiopia.

This study revealed the differences and commonalities of ideational factors as determinants of contraceptive use intentions in the four emerging regions of Ethiopia. The findings showed that for each region, higher contraceptive ideation scores were associated with greater intention of future contraceptive use. This finding is consistent with previous findings suggesting that higher contraceptive ideation is one important means to promote intentions to use contraceptives [8, 18‐20]. Even with differences in contraceptive prevalence and reproductive health outcomes across the four emerging regions of Ethiopia, a similar positive correlation of contraceptive ideation and the intent to use contraceptives was observed in each of the regions.

We observed variation across regions on the effect of ideational factors on intention to use contraception. Of the five dimensions of ideation, self-efficacy was an important predictor of the intention to use contraception in all regions of the study, a result consistent with evidence from prior research [19, 20]. Rejection of myth and rumor was the other important dimension of ideation in all regions except in Somali. Contraception awareness and family support were significant in Afar region only. In Afar household decision making, men are generally the authority figure and have the final say [21]. This might be the reason for the strong influence of family support as the strong determinant of the intent to use FP.

The role that the different ideation dimensions play in contraceptive use intention can help guide health education initiatives. The results from this study provide information to regional/district health offices to tailor their areas of focus to improve future contraceptive use. Self-efficacy was found to be a significant predictor variable on the intent to use contraceptives in all the four regions. Thus, the communication programs in the four regions should focus on increasing self-efficacy for contraceptive use. Strategies for strengthening self-efficacy for contraceptive use should include encouraging clients to use contraceptives for the first time and develop mastery of the practice. Along with communications emphasizing self-efficacy, regional/district health offices should identify and address psychological, logistic, and structural barriers to contraceptive access. Family planning programs should provide opportunities for women to learn and practice how to communicate with their spouses about contraceptive use. Other relevant strategies should include opportunities for the audience to learn from a satisfied contraceptive user similar in other respects to the non-using audience. Observing relevant behaviors in others allows one to form “a conception of how new behavior patterns are performed, and on later occasions the symbolic construction serves as a guide for action” [22]. Modeling relevant behaviors can be implemented in small groups or through the mass media. Promoting discussion about contraceptive use with significant others and encouraging personal advocacy in favor of contraceptive use among the intended audience are also important to build self-efficacy.

The rejection of myth and rumor dimension of ideation was found to be a significant predictor variable on the intent to use contraceptives in Afar, Benishangul-Gumuz, and Gambela. For these regions, effectively demystifying myths and rumors about contraceptives through strategically designed messages that provide factual information on contraceptives will be vital to improve the intention to use contraceptives. Mass media and community conversations that allow participants to discuss the prevailing myths about contraceptives in their community and critically examine their personal beliefs about contraceptives may be helpful. Given the important role of family support in Afar, the relevant regional/district health office should broaden the reach of family planning education programs to include in-laws—particularly mothers-in-law—to shift ideation of contraceptive use.

In addition to the ideation factors, we found other sociodemographic variables that predicted the intent to use contraceptives and that aligned with previous findings in the literature. In the Afar and Benishangul-Gumuz regions, education was found to be a positive predictor on intention to use contraceptives. Women’s educational level on contraceptive use has been well documented, especially in developing countries where high proportions of women are not using FP services [19, 23‐25]. However, we did not see the same effect in Gambela and Somali region, perhaps because everyone (educated or not) adheres to decrees from ethnic/religious leaders.

Younger women had higher intentions to use contraceptives in the future. Studies in low and middle income countries [19, 23] reveal that younger women are more likely to use FP services than older women. This difference may be due to continuous education attainment opportunities that might improve a younger generation’s knowledge about utilizing contraception.

In this study, women’s place of residence affects contraception use intention. In particular, women belonging to a pastoralist community had lower intentions of using contraceptives compared with non-pastoralist ones, consistent with other studies [24, 26]. Pastoralist communities of Ethiopia, which are hard to reach and mobile, have comparatively less access to and provision of health care services such as medicines, health equipment, health providers, and other services. These factors combine to result in low quality, high cost services; coupled with the lack of transportation, these factors result in unmet demand for health services, including family planning.

Parity had an uneven effect. In Afar and Gambela regions, women who had a greater number of children expressed less the intent to use contraceptives, whereas the opposite was true for Benishangul-Gumuz, where women’s intention to use contraceptives increased as the number of children increased. Similar research from Bangladesh [23] showed that women with large number of children tended to use contraceptives more compared to women with fewer children.

This study has limitations. The information collected is self-reported. There is, therefore, the possibility that the ideation and intention to use family planning responses may have been affected by social desirability bias. Prior to data collection, the data collectors were trained to minimize subjectivity and the influence of social desirability. Only selected districts were included in the study raising the question of generalizability; this may not be an important issue in the Somali and Afar regions, which have a homogeneous ethnic and religious distribution. For the Benishangul-Gumuz and Gambela regions, however, where there is ethnic diversity, we attempted to include districts from each ethnic group.