By - Selam Yilma (MPH) & Wubegzeir Mekonnen ( PhD ) ASSESSMENT OF KNOWLEDGE, ATTITUDE AND INTENTION TO USE LONG ACTING AND PERMANENT CONTRACEPTIVE METHODS AMONG WOMEN IN HIV CHRONIC CARE, ADDIS ABEBA, ETHIOPIA By - Selam Yilma (MPH) & Wubegzeir Mekonnen ( PhD )

Presentation outline Introduction Objective Methodology Result and Discussion Strength and Limitation of the Study Conclusion Recommendation 11/14/2018 Selam Yilma Selam Yilma

Introduction Long-acting and Permanent Methods (LAPMs) include the intrauterine device (IUD) and the progestogen implant, as well as male and female sterilization. (K4Health) LAPMs can provide highly effective protection from unwanted pregnancies and, thus, mother-to-child transmission of HIV. Unintended pregnancies can be prevented by using LAPMs but it is poorly understood among HIV positive women.(FHI the case of LAPM 2007) he CPR is highly dependent on short-term family planning methods, nearly 21% for injectables. (RH strategy 2006-2015) To increase the CPR, the Federal Ministry of Health (FMOH) has considered the important role of LAPMs. Prevalence of LAPMs is still low (4.2%) and little evidence is available among women in HIV chronic care. 11/14/2018 Selam Yilma Selam Yilma

Introduction Cont. The utilization of LAPMs is very low (4.2%) among women of reproductive age group. (EDHS 2011). There are little evidence showing knowledge, attitude, intention to use LAPMs & barriers for low utilization of this method among women in HIV chronic care. Ethiopia has made progress in doubling the CPR over the last five years (from 15% in 2005 to 29% in 2011). (EDHS 2005, 2011) It is very important to conduct research on the area of women’s KAI to use LAPMs women in HIV chronic care in public and private facilities. This study will contribute to fill the information gap to scale up LAPMs which is given due emphasis by the Federal MOH. 11/14/2018 Selam Yilma

Conceptual framework Intention to use LAPMs Clinical factor Socio demographic and economic factor Age Educational Status and husband’s educational status Occupational status and husband’s occupational status Marital Status Religion Household monthly income Clinical factor WHO Clinical Staging CD4 Reproductive factor Age at first marriage Decide on the No of children Household size Total number of children Intention to have another child Ever use of family planning methods Current use of short term family planning methods Intention to use LAPMs Knowledge, Attitude & other characteristics to use LAPMs Knowledge Attitude Myths and misconception heard on LAPMs Availability of trained personnel 11/14/2018 Selam Yilma

OBJECTIVES General Objective To assess the knowledge, attitude and intention to use long acting and permanent contraceptives methods and its determinants and barriers among women in HIV chronic care in Addis Ababa, Ethiopia. Specific Objectives To measure the knowledge, attitude and intention to use LAPMs among women in HIV chronic care in Addis Ababa. To identify factors associated with the intention to use LAPMs among women in HIV chronic care in Addis Ababa. To explore barriers on the use of LAPMs among women in HIV chronic care in Addis Ababa. 11/14/2018 Selam Yilma

Methods (1) Study area- conducted in Addis Ababa. Study period- February-March 2016. Study design cross-sectional study design with mixed methods Populations Source population- all women in HIV /AIDS chronic care in Addis Ababa. Study Population Quantitative method - all women of reproductive age group in HIV chronic care selected public and private facilities in Addis Ababa Qualitative method- MsG on adherence & their service providers Sample size Method Quantitative method- Determined by the single population proportion formula using the following assumptionsn= (Zα/2)2 P (1-P) / d2 = (1.96)20.385 (1-0.385)/ (0.05)2,= 364 Adding a 10 % non-response rate gave the required minimum sample size n = 400 Quantitative method-A total of 5 mother support group &5 ART service providers. 11/14/2018 Selam Yilma

Sampling procedure Method (3) 11/14/2018 Selam Yilma

Method (4) Data quality assurance Study variables Dependent Variable- Intention to use LAPMs Independent variables- Socio-demographic and economic factor, RH factor, Knowledge, Attitude, Myth and misconception. Study tools (questionnaires, guides ) Quantitative Study- interviewer administered structured questionnaires. Qualitative Study -An in depth interview guide developed by the PI Data quality assurance Quantitative Study - Training, Pre-test, Supervision, rechecking for completeness, entry using soft ware ,designing a data entry template with internal consistency check schemes. Qualitative Study- Data were audio taped + note was taken to double check its quality, the PI moderated the interview Transcription was also done by the PI. 11/14/2018 Selam Yilma

Data Entry, Cleaning and Analysis Quantitative Study Data entered in EPI Info version 7 The data edited, cleaned and analyzed using STATA 12 The summary measures include mean, median value and proportions. Statistical significance was tested using Chi-square Bivariate and multivariate logistic regression Qualitative Study Audio information Transcribed Translated Imported to open code Coded categorized & merged into thematic areas result was narrated. Ethical Consideration The research ethics committee of the SPH, College of Health Sciences in AAU Written permission-health bureau of the Addis Ababa city government. Consent obtained from medical directors &Informed verbal consent was also obtained from individual participants. 11/14/2018 Selam Yilma

Result and discussion A total of 400 women in HIV chronic care were included in this study, which makes the response rate to be 100%. The mean age of women in HIV chronic was 32 (6.16 SD). Among women in HIV chronic care 299 (72.75%) women had 0-2 children, while the rest had 3 and more children. Decision on the number of children were made women herself 94(48.5%) jointly with her husband 57 (29.38%) rest 43(22.16%) of decision made by her husband. Majority 346(86.5%) of women started ART and the rest of them 54(13.5%) were on pre-ART. 11/14/2018 Selam Yilma

Women’s knowledge on LAPMs This finding is different with study done in South Africa-90% know female sterilization (Sarah et al ,2012) Addis Ababa-86.6% know IUD (Bantamlak ,2014) Consistent Zimbabwe (Pester ,2013) Wolaita zone (Mengistu et al,2014) EDHS 2011 knowledge on Implant was 67.8% 11/14/2018 Selam Yilma

Attitude of women’s towards use f LAPMS Women’s intention to use LAPMs More than half 212(53%) of women had negative attitude to use LAPMs. This finding is quite similar with study done in Wolaita zone 52.6%(Mengistu et al,2014) Mekelle-53.6% (Mussie et al,2014) Addis Ababa 49.9% (Bantamlak ,2014) This could be due to the difference myth and misconception in the community, in which women are developing negative attitude on LAPMs. From a total of 400 women who participated in the study, only 110 (27.5%) had the intention to use LAPMs. Lower than the study done in Addis Ababa 38.5% (Bantamlak ,2014) Mekelle-53% (Hailay et al,2014) Debremarkos -45.9% (Amanuel,2014) The FMOH recognizes the important role & contribution of the private sector to Health but little effort is done to increase LAPMs user in private (FMOH FP guidline,2011). 11/14/2018 Selam Yilma

Ever use and Intended LAPMs Not consistent with the study done in Pakistan (Sohail ,2010) 11/14/2018 Selam Yilma

Barriers, myths and misconceptions on the LAPMs 58.2% women were thinking there are barriers to use LAPMs, similarly, 55.75% of women heard myths and misconception on LAPMs. The barrier mentioned by interviewer was husband refusal not to use LAPMs this was explained by member of mother support group as: “I had experience at one time the husband came before me and said who do you think you are? You inserted this inside my wife, you should remove what you put in my wife…..did you eat unpeeled banana? That you said you have to use condom too…...” 30 years old married mother support group 11/14/2018 Selam Yilma

Myths and misconceptions This finding is supported by In-depth interview by health provider working in health center explained the situation as: “They relate the family planning with the result that it makes them fat or thin. If it makes them thin they thought that other persons suspect that they are HIV positive. And if it makes them fat they thought that other persons suspect that they are taking other drugs.um… what if it sucks my blood and finish, cause to me cancer…. I do not want to add other incurable diseases.um…it may leads me to hypertension …. diabetes mellitus?..........” 32 years old female BSc nurse from hospital 11/14/2018 Selam Yilma

Table 8: Factors associated with women’s intention to use LAPMs in Addis Ababa, Ethiopia, May, 2016 Characteristics  Yes N (%)  No  COR (95% CI) AOR (95%CI) Total number of children   0-2 children 55(18.5%) 236(81.1) Ref 3-7 Children 55(18.5) 54(49.5) 4.4(2.71,7.04)* 3.28(1.22-8.78)** Decide on the number of children Husband 11(25.58) 32(74.42) Myself 14(14.89) 80(85.11) 0.51(0.21-1.24) 0.49(0.15-1.64) Me and Husband 46(80.70) 11(19.30) 12(4.7-31.4)* 20(5.09-80.45)** Ever use of LAPMs Yes 40(46.51) 46(53.49) No 70(22.29) 244(77.71) 3(1.83-4.99)* 2.85(1.05-7.79)** Knowledge Low knowledge 25(15.63) 135(84.38) High Knowledge 85(35.42) 155(64.58) 2.96(1.79-4.89)* 10(3.11-33.4)** 11/14/2018 Selam Yilma

Factors associated with women’s intention to use LAPMs Women who never ever use LAPMs were AOR=2.85: 95% CI (1.22, 8.78) times more likely to use LAPMs than women who ever use LAPMs. Inconsistent with the study done in Bale zone South east Ethiopia (Abulie et al,2012) Wolaita (Mengistu et al,2014)- no association This particular finding could be the fact that those who ever used LAPMs may face side effects and fear to suffer again. This situation explained by 30 years old widowed MsG as: “……The previous pain and feeling will remain in their mind. They said at the time am using it I was sick that’s why am removed it so, why should I inserted it again ……” positive significant association 11/14/2018 Selam Yilma

Factors associated with women’s intention to use LAPMs Women who had two or more total children were AOR=3.28: 95% CI (1.22, 8.78) times more likely to use LAPMs than those who had less than 2 children. Consistent Malawi (Owen,2012) Addis Ababa (Bantamlak ,2014) Not consistent Wolaita(Mengistu et al,2014) Tigray (Alem et al,2014) This could be due to increased living cost and better awareness about family planning in urban areas The situation explained by 38 years old married mother support group as: “The one who live in urban area more or less have the awareness of family planning because now days living by itself become family planning. The life style is teaching more rather than giving condom and pills to prevent pregnancy because at this time how much will cost milk? It cost six hundred birr….. “ 11/14/2018 Selam Yilma

Factors associated with women’s intention to use LAPMs Women who had decided on the use of family planning together with their husband were highly significant AOR=20: 95%CI (5.09- 80.45) with careful interpretation of the statistical value. Consistent Butajira south central Ethiopia(Wubegzier et al ,2011) Women who had higher knowledge score were AOR=10: 95%CI (3.11, 33.4) times more likely to use LAPMs than women who had low knowledge score. Consistent Kenya(Paul et al,2014) Addis Ababa (Bantamlak ,2014) Inconsistent West shoa zone (Eshetu et al ,2015) Wolaita (Mengistu et al,2014) 11/14/2018 Selam Yilma

Strengths and Limitations of Study Strength of the Study The study used mixed design & The Study provides a baseline information. Limitation of the study The study does not include men as study participant & Since the study was institutional based, that might undermine generalizing the result to the general population. Conclusions The intention to use LAPMs was low in this study area. women who never ever use LAPMs women who had two or more total children women who decided on the use of family planning together with their husband and women who had higher knowledge have significant association with intention to use LAPMs among women in HIV chronic care. Fear of drug reaction, fear of drug burden, fear of previous side effect partner disapproval, family and in-laws interference in decision making, perceived service related problems and low awareness on permanent methods were also barriers not to use LAPMs in the study area. Strengths and Limitations of Study 11/14/2018 Selam Yilma

Recommendations Addis Ababa health bureau together with FMOH should give due emphasis on awareness creation, Information, education and communication. ART provider working in ART clinic shall inform and educate PLWHA about prevention of unwanted pregnancy and use of family planning particularly LAPMs. Further research should be conducted using strong study design at community level. 11/14/2018 Selam Yilma

Acknowledgment I would like to thank almighty God for His support in all my work. My advisor Dr. Wubegzier Mekonnen Addis Ababa University , School of Public Health Health professionals working in different facilities Study participant Data collectors My family and friends 11/14/2018 Selam Yilma

Thank You 11/14/2018 Selam Yilma