J Community Health DOI 10.1007/s10900-015-0057-6
ORIGINAL PAPER
Knowledge and Usage of Emergency Contraceptives Among University Students in Ghana Eugene Kofuor Maafo Darteh1 • David Teye Doku1
Ó Springer Science+Business Media New York 2015
Abstract Contraceptive use is an important strategy for the prevention of unwanted pregnancy and avoidance of induced abortion. Of all the contraception methods, emergency contraceptive (EC) offers the last chance to achieve this. However, few studies have documented the use of EC among young people in Ghana. This study explored knowledge and usage of EC as well as the factors associated with it among University of Cape Coast students. Data were obtained on the knowledge and usage of ECs among University of Cape Coast students in 2013. Logistic regression analysis was used to investigate the association between students’ socio-demographic characteristics and EC knowledge and use. More male students (72 %) than females (59 %) were sexually active. Fifty-seven percent of the respondents had ever heard of EC and 36 % had ever used EC. Although males were more likely to be sexually active, females were more likely to have knowledge of EC use compared to males. The study underscores the need to increase awareness regarding EC among University students in order to offer them the opportunity that EC provides if other forms of contraceptives are missed. Keywords Emergency contraceptives Ghana Knowledge Usage University students
& Eugene Kofuor Maafo Darteh [email protected] David Teye Doku [email protected] 1
Department of Population and Health, University of Cape Coast, Private Mail Bag, Cape Coast, Ghana
Background Unwanted pregnancy and its related health problems such as maternal and infant mortality resulting from unsafe abortion is a global public health problem. Globally, it is estimated that 44 million pregnancies end in abortion each year [1]. Estimates suggest that in 2008, one in five pregnancies ended in abortion and nearly half of these abortions were unsafe [2]. These estimates vary by region. Although Africa has lower abortion rates compared to Latin America, the percentage of unsafe abortion of 97 % is staggering; especially in Western Africa where available data indicate that nearly all abortions were unsafe [2]. Contraceptive use is an important strategy for the prevention of unwanted pregnancy and avoidance of induced abortion. In developing countries where there is high fertility rate, contraceptive use is also important for controlling population growth in order to ensure qualitative human and socioeconomic development. Cleland et al. [3] indicate that contraceptive use in developing countries has reduced the number of maternal mortality by 44 % which is about 270,000 deaths prevented in 2008 but could prevent 73 % if the full demand for birth control were met. Contraceptive is therefore critical in achieving the UN Millennium Development Goal 5 (MDG 5); to reduce maternal mortality and achieve universal access to reproductive health. Ghana’s population continues to rise at an alarming growth rate of about 3 % according to Population and Housing Census [4]. The most recent national data available on contraceptives indicate that although there is high knowledge about contraceptives, the usage is low [5]. Among married women 15–49 currently using any method and any modern method of contraceptive were 24 and 17 %, respectively from 2003 to 2008 [5].
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Ghana formulated a national family planning policy already in the mid 1960s. The goal of the policy among other things was to initiate programmes that will help reduce the high total fertility rate of over 5, particularly, through increased contraceptive use. Despite this effort, the total fertility rate of Ghana is 4.4 [5]. The use of emergency contraceptive (EC), to prevent pregnancy within 72 h after unprotected sexual intercourse, in particular, offers women who are not on regular conceptive a last resort to prevent unintended pregnancy and its related health issues. Numerous studies have been conducted on the knowledge of university students on ECs in the Sub-Saharan Africa [6–10]. These studies have reported varied levels of knowledge of ECs for Nigeria (50.7 %), Uganda (45 %), Cameroon (67 %), Ethiopia (43.5 %) and South Africa (56.5 %). In Ghana, few studies have been conducted on ECs among university students [11, 12]. In their study, Addo and Tagoe-Darko [11] observed that 51 % of the students had heard of ECs. An earlier study by Baiden et al. [12], observed that 43.2 % of the 194 respondents had heard of modern EC methods with only 11.3 % indicating correctly the recommended time within which emergency contraceptive pills (ECPs) are to be taken after unprotected sex. What was missing in both studies is the determinants of students’ knowledge of ECs. This study attempts to fill the gap by examining the factors that predict university students’ knowledge and use of ECs. University students are among innovators involved in the adoption and spread of innovation in many spans of society. They are, therefore, expected to lead in both the knowledge and usage of ECs. However, we are not aware of any study on the knowledge or use of ECs among young adults in Ghana in the past decade. The goal of this study is to explore to what extent university students in Ghana have knowledge of and use ECs and explore the drivers of ECs knowledge and use.
Methods Data for the study were collected from a survey of resident students of the University of Cape Coast in Ghana. The University of Cape Coast is one of the six public (State owned) universities in Ghana. It has total population of about 24,000 pursuing various academic programmes in the field of Agriculture, Arts, Education, Physical Sciences, Social Sciences and Law and Medicine. At the time of the data collection the Faculty of Law was just in the process of admitting it maiden students and therefore the study did not include students of that Faculty. The University has 8 Halls of residence, which accommodate about 6000 residential students. The University operates a residential
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policy where all freshmen are accommodated in the traditional halls of residence while continuing students make their own arrangements for accommodation. A total of 571 students (283 males and 288 females) were randomly sampled and interviewed. Using a two-page questionnaire, information on the background characteristics of respondents, knowledge of ECs and usage of ECs were collected. Informed consent was obtained from all participants. At the time of the study no functional Institutional Review Board existed at our institution. The outcome variables used in this paper are knowledge of ECs and usage of ECs. These variables had dichotomous responses 0 = No and 1 = Yes. The explanatory variables included sex of respondents, age of respondents, age at first sex, number of sexual partners, circumstance of first sex, ethnicity and residential status. Age was grouped into 17–19, 20–24, 25–19, 30–34 and 35?. Age at first sex was grouped into less than 15, 15–19, 20–24, 25–29 and 30?. Number of sexual partners was grouped into 1, 2–3 and 4?. Residential status was divided into ‘‘resident’’ and ‘‘nonresident’’. To reflect the major religious groupings in Ghana, religion was grouped into Protestants, Catholics, Pentecostal/Charismatics, Muslims and Others. Ethnicity was categorised into Akan, Mole-Dagbani, Ewe, Ga/ Adangbe, Other Ghanaians and Non-Ghanaians. Chi square and logistic regression analysis were the statistical tools used in data analyses. The result of the logistic regression analyses are reported as odds ratios (OR) at 95 % confidence interval (CI). The Stata software was used for the data analyses.
Results Knowledge and Utilization of Emergency Contraceptives Among University Students More than two-thirds of the respondents were aged 20–24 years and about 15 % were aged 25–29 years. Twenty-nine percent of the respondents were in level 300 while 28 % were in the final year of their four year undergraduate studies. About 8 % of the students were married and the rest were not. More than half of the students interviewed were Akans with \1 % being foreign students. More than 90 % of the respondents professed one Christian faith or the other (Protestants—31 %; Catholics—22 %; Pentecostals—38 %) and 6 % were Muslims. About 56 % of the respondents were non-residents (those in the diaspora) with about 44 % being residents in the traditional halls of residence. Sixty-five percent of the respondents had ever had sexual intercourse. There was a statistically significant difference in the proportion of males and females who had ever had sex (v2 = 11.3221;
J Community Health Table 1 Background characteristics of respondents Variables
Males (N = 283)
Females (N = 288)
Total
Ages of respondents \20
Table 1 continued v
2
(N = 149)
5.790
Has a friend ever used EC
0.946
2.83
5.90
4.38
Yes
52.35
57.69
55.29
20–24
73.14
75.69
74.43
No
47.65
42.31
44.71
25–29
15.90
13.19
14.54
30–34
5.65
3.47
4.55
Yes
35.57
37.36
36.56
35?
2.47
1.74
2.10
No
64.43
62.6
63.44
Level 100
19.08
22.92
21.02
Daily
Level 200
21.91
20.14
21.02
Weekly
11.54
5.80
8.26
Level 300
28.62
29.86
29.25
Monthly
26.92
26.09
26.45
Level 400 Ever married
30.39
27.08
28.72
Occasionally
55.77
68.12
62.81
Level of education
7.77
7.99
7.88
92.23
92.01
92.12
59.72
59.03
59.37
6.01
4.51
5.25
Ethnicity Mole-Dagbani Ewe
0.114
Frequency of use
5.891 5.77
0.009
No Akan
Ever used EC
1.830
Yes
6.400
19.79
18.06
18.91
Ga Dangbe
8.13
12.15
10.16
Other Ghanaian
5.30
6.25
5.78
Non-Ghanaian
1.06
0.00
0.53
Religion
0.00
N = 52
N = 69
2.48
N = 121
When is EC supposed to be used Anytime after sex
50.00
34.78
41.32
Within 48 h after sex during ovulation
38.46
60.87
51.24
Others
11.54
4.35
7.44
29.05
38.46
34.24
Preferred source of EC Clinic/hospital 3.409
5.738
Health worker
11.49
9.89
10.61
Chemist/drug store
46.62
45.05
45.76
30.39
32.64
31.52
Others
7.43
3.85
5.45
Catholic
24.03
20.14
22.07
Don’t know
5.41
2.75
3.94
Pentecostal
39.58
38.19
38.88
5.30 0.71
7.29 1.74
6.30 1.23
Non-resident
55.48
55.90
55.69
Resident
44.52
44.10
44.31
Yes
72.08
58.68
65.32
No
27.92
41.32
34.68
Yes
51.59
62.50
57.09
No
48.41
37.50
42.91
(N = 146)
(N = 180)
(N = 326)
Residential status
Source: Fieldwork, 2013 0.0105
Ever had sex
11.3221***
Ever heard of EC
6.935**
Source of information on EC
v2 3.4713
Radio
45.89
43.33
44.48
Health worker
15.75
17.22
16.56
Peer educators
4.11
7.22
5.83
Friends
24.66
26.67
25.77
Others
9.59
5.56
7.36
v2 6.629**
Protestant
Moslem Others
v2
(N = 182) (N = 331)
p \ .001). Fifty-seven percent of the respondents had ever heard of ECs while the rest had never heard of them. Also, there was a significant difference in the proportion of males and females who had ever heard ECs (v2 = 6.935; p \ .05) (see Table 1). Among those who had ever heard of ECs, 44 % indicated that their source of information was the radio while 26 % indicated that their source of information was friends. Fifty-five percent of the respondents knew a friend who had ever used ECs. More than a third of the respondents had ever used an EC, and more than 60 % indicated that they used ECs occasionally while 26 % used it monthly. With regards to when the contraceptive is supposed to be used, 51 % indicated that it should be used within 48 h of after sex during ovulation with 41 % indicating that it should be used anytime after sexual intercourse. There was a statistically significant difference in the respondents’ knowledge regarding when ECs are to be used. More than 45 % of the students considered
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J Community Health Table 2 Logistic regression model showing the relationship between socio-demographic factors and knowledge of ECs
Predictors
Model 1 OR
95 % CI
Model 2 OR
95 % CI
Sex of respondent Male
Ref
Female
1.564**
Ref 1.120–2.183
2.804***
1.688–4.658
Age groups 17–19
Ref
20–24
2.22
0.959–5.136
Ref 3.961
25–29
3.492**
1.371–8.894
4.234
0.810–22.130
30–34
2.844
0.913–8.861
3.711
0.608–22.630
35?
8.889**
1.585–49.833
11.778**
1.193–116.281
\15 15–19
Ref 0.749
0.230–2.440
Ref 0.543
0.150–1.968
20–24
0.642
0.194–2.130
0.514
0.140–1.891
25–29
0.606
0.131–2.792
0.296
0.050–1.762
30?
0.485
0.074–3.191
0.216
0.025–1.872
0.829–18.911
Age at first sex
Number of sexual partners 1
Ref
02–3
0.992
0.611–1.611
Ref 1.25
0.731–2.136
4?
2.598
0.956–7.057
3.634**
1.224–10.786
Was first sex planned Planned
Ref
Just happened
0.703
.447–1.103
Ref 0.644
0.394–1.051
Forced
1.105
.432–2.827
0.973
0.338–2.802
Residential status Resident
Ref
Non-resident
0.677**
Religion Protestant
Ref 0.485–0.946
Ref
0.913
0.570–1.463
Ref
Catholic
1.423
0.892–2.269
1.029
0.517–2.049
Pentecostal
1.074
0.723–1.595
0.784
0.443–1.389
Moslem
0.732
0.357–1.499
0.468
0.156–1.400
Others
1.091
0.237–5.015
0.336
0.061–1.847
Ethnicity Akan
Ref
Ref
Mole-Dagbani
1.664
0.757–3.663
2.266
0.699–7.343
Ewe
1.211
0.780–1.879
1.063
0.581–1.947
Ga/Dangme
1.467
0.824–2.611
1.193
0.539–2.640
Other Ghanaian
0.999
0.824–2.611
0.853
0.259–2.810
Non Ghanaian
1.66487
0.149–18.535
1.294
0.882–18.987
Source: Fieldwork, 2013 *** p \ .001; ** p \ .05; * p \ .10
chemical/drug stores as their preferred source of the ECs with 34 % indicating that they preferred clinics/hospitals. Multivariate Results Bi-nomial logistic regression was used to examine the determinants of students’ knowledge of EC methods. The
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results show that there was a significant relationship between sex and knowledge of ECs. For instance, females were 2.8 times more likely to know of EC methods compared to males (reference) (p \ .001). Age was significantly related to knowledge of ECs with the odds highest among those aged 35 years and above compared to those aged 17–19 years (p \ .001). A significant relationship was
J Community Health Table 3 Logistic regression model showing the relationship between socio-demographic factors and use of ECs
Predictors
Model 1 OR
95 % CI
OR
95 % CI
Sex of respondent Male
Ref
Ref
Female
1.0804
1.856**
1.024–3.364
Age groups 17–19
Ref
20–24
4.335
0.533–35.25
3.772
Ref 0.290–49.009
25–29
5.091
0.672–49.205
4.14
0.300–57.164
30–34
5.091
0.518–50.004
4.448
0.271–72.933
35?
12.00**
1.057–136.793
10.532
0.559–198.219
\15 15–19
Ref 1.106
0.340–3.598
Ref 0.758
0.210–2.730
20–24
0.7
0.208–2.350
0.496
0.133–1.840
25–29
0.25
0.036–1.703
0.122
0.013–1.120
30?
0.333
0.026–4.186
0.142
0.008–2.370
Age at first sex
Number of sexual partners 1
Ref
02–3
1.383
0.783–2.445
1.664
Ref 0.868–3.191
4?
1.826
0.765–4.359
1.968
0.729–5.309
Was first sex planned Planned
Ref
Just happened
0.569**
0.337–0.959
0.495
Ref 0.280–0.876
Forced
0.604
0.225–1.620
0.432
0.150–1.245
0.634–1.578
1.257
Residential status Resident
Ref
Non-resident
1.001
Religion Protestant
Ref
Ref
0.718–2.200
Ref
Catholic
0.975
0.533–1.785
0.998
0.468–2.124
Pentecostal
0.868
0.504–1.495
0.858
0.445–1.653
Moslem
0.691
0.226–2.113
0.624
0.137–2.843
Others
?
?
Ref
Ref
Ethnicity Akan Mole-Dagbani
1.585
0.625–4.022
0.904
0.268–3.055
Ewe
1.428
0.804–2.534
1.435
0.692–2.973
Ga/Dangme
1.049
0.501–2.198
0.864
0.367–2.034
Other Ghanaian
0.969
0.347–2.701
1.635
0.325–8.244
Non Ghanaian
1.937
0.119–31.487
1.269
0.065–24.819
? omitted *** p \ .001; ** p \ .05
observed between number of sexual partners and knowledge of ECs with students with 4 or more partners being 3.6 times more likely to know of ECs compared to those with a partner (p \ .05) (Table 2). A bi-nomial logistic regression was also used to examine the relationship between socio-demographic characteristics
and use of ECs among the respondents. Results in the Table 3 show that there was a significant relationship between sex of respondents and decision to use ECs. For instance, females were more likely to take decisions regarding the use of ECs compared to males (OR = 1.8; p \ .05) (Table 3).
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J Community Health
Discussion More than half (65 %) of the University of Cape Coast students reported being sexually active. This is higher than those found among Ethiopian students [13] and in a number of African countries [14]. Majority of male students (72 %) were sexually active compared to 59 % of female students. The common sources of information on EC were radio (44 %) and friends (25 %). This study suggests that knowledge of EC use was low among the University of Cape Coast students, although majority were sexually experienced. This finding is comparable with those found among university student in Durban, South Africa [10] but lower than those found in Cameroon [8] and higher than those reported among Ghana students in 2009 [11], in Nigerian students [6], Ugandan students [7] and Ethiopian University students [9]. Interestingly, although males were more likely to be sexually active, females were more likely to have knowledge of EC use compared to males. Available literature suggests that gender disparities exist with respect to reproductive health among young people to the detriment of females [15, 16]. Already at young age males tend to exert their masculine influence on their female counterparts with respect to reproductive health decision-making. This influence expands over the use of contraceptives, abortion and sexual activity. Male adolescents also favour and encourage male sexual initiation among young males but frown on it among young females. The desire to prevent losing their partners may hinder young females from making informed reproductive health decisions while the quest to keep sexual relationship secret may contribute to young people (both males and females) unwillingness to utilize reproductive health services even where they are available. Females are most likely to suffer most of the burden of unwanted pregnancy than males and are therefore most likely to be concerned about contraceptive use including ECs. Also in a typical African setting, females are the primary target of reproductive health education rather than males. These issues could explain the gender differences found in the knowledge of EC use in this study. We expect University students to be among the innovators with respect to the experimentation and usage of products such as ECs, which is not very popular in Ghana, for example, in the Ghana Demographic and Health Survey EC was rarely mentioned as a contraceptive method [5]. Therefore, the relatively low usage of ECs found in this study suggests the need for awareness creation among the youth regarding this available ‘‘last chance’’ option of contraception.
Conclusion Although most of the respondents were sexually active, knowledge of EC as well as it use was relatively low among them. The low level of EC use is consistent was
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finding from Senegal [17] and elsewhere [8, 10]. More male students were sexually active than female students. However, knowledge of EC use was higher among female students than their male counterparts. The study underscores the need to increase awareness regarding EC among university students in other to offer them the opportunity that EC offers if other forms of contraception are missed. The radio and friends can be some of the important sources for such a campaign.
References ˚ hman, E., & Shah, I. H. 1. Sedgh, G., Henshaw, S., Singh, S., A (2007). Induced abortion: Estimated rates and trends worldwide. The Lancet, 370(9595), 1338–1345. 2. Sedgh, G., Singh, S., Shah, I. H., Ahman, E., Henshaw, S. K., & Bankole, A. (2012). Induced abortion: Incidence and trends worldwide from 1995 to 2008. Lancet, 379(9816), 625–632. 3. Cleland, J., Conde-Agudelo, A., Peterson, H., Ross, J., & Tsui, A. (2012). Contraception and health. Lancet, 380(9837), 149–156. 4. Ghana Statistical Service (GSS). (2012). Population and housing census of Ghana. Summary Report of Final Results. Accra, Ghana: Sakoa Press Limited. 5. Ghana Statistical Service (GSS), Ghana Health Service (GHS), & ICF Macro. (2009). Ghana demographic and health survey 2008. Accra: GSS, GHS, and ICF Macro. 6. Akani, C. I., Enyindah, C. E., & Babatunde, S. (2008). Emergency contraception: Knowledge and perception of female undergraduates in the Niger Delta of Nigeria. Ghana Medical Journal, 42(2), 68–70. 7. Byamugisha, J. K., Mirembe, F. M., Faxelid, E., & GemzellDanielsson, K. (2006). Emergency contraception and fertility awareness among university students in Kampala, Uganda. African Health Sciences, 6(4), 194–200. 8. Kongnyuy, E. J., Ngassa, P., Fomulu, N., Wiysonge, C. S., Kouam, L., & Doh, A. S. (2007). A survey of knowledge, attitudes and practice of emergency contraception among university students in Cameroon. BMC Emergency Medicine, 7(1), 7. 9. Tamire, W., & Enqueselassie, F. (2007). Knowledge, attitude, and practice on emergency contraceptives among female university students in Addis Ababa, Ethiopia. Ethiopian Journal of Health Development, 21(2), 111–116. 10. Roberts, C., Moodley, J., & Esterhuizen, T. (2004). Emergency contraception: Knowledge and practices of tertiary students in Durban, South Africa. Journal of Obstetrics & Gynecology, 24(4), 441–445. 11. Addo, V. N., & Tagoe-Darko, E. D. (2009). Knowledge, practices, and attitudes regarding emergency contraception among students at a university in Ghana. International Journal of Gynecology & Obstetrics, 105(3), 206–209. 12. Baiden, F., Awini, E., & Clerk, C. (2002). Perception of university students in Ghana about emergency contraception. Contraception, 66(1), 23–26. 13. Wegene, T., & Fikre, E. (2007). Knowledge, attitude, and practice on emergency contraceptives among female university students in Addis Ababa, Ethiopia. Ethiopian Journal of Health Development, 21(2), 111–116. 14. Sekirime, W. K., Tamale, J., Lule, J. C., & Wabwire-MAngen, F. (2001). Knowledge, attitude and practice about sexually
J Community Health transmitted diseases among university students in Kampala. African Health Sciences, 1(1), 16–22. 15. Mmari, K., & Sabherwal, S. (2013). A review of risk and protective factors for adolescent sexual and reproductive health in developing countries: An update. Journal of Adolescent Health, 53, 562–572. 16. Meekers, D., & Calves, A. (1991). Gender differentials in adolescent sexual activity and reproductive health risks in Cameroon. African Journal of Reproductive Health, 3, 51–67.
17. Mane´, B., Brady, M., Ramarao, S., & Thiam, A. (2014). Emergency contraception in Senegal: Challenges and opportunities. European Journal of Contraception and Reproductive Health Care. doi:10.3109/13625187.2014.951995.
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ORIGINAL PAPER
Knowledge and Usage of Emergency Contraceptives Among University Students in Ghana Eugene Kofuor Maafo Darteh1 • David Teye Doku1
Ó Springer Science+Business Media New York 2015
Abstract Contraceptive use is an important strategy for the prevention of unwanted pregnancy and avoidance of induced abortion. Of all the contraception methods, emergency contraceptive (EC) offers the last chance to achieve this. However, few studies have documented the use of EC among young people in Ghana. This study explored knowledge and usage of EC as well as the factors associated with it among University of Cape Coast students. Data were obtained on the knowledge and usage of ECs among University of Cape Coast students in 2013. Logistic regression analysis was used to investigate the association between students’ socio-demographic characteristics and EC knowledge and use. More male students (72 %) than females (59 %) were sexually active. Fifty-seven percent of the respondents had ever heard of EC and 36 % had ever used EC. Although males were more likely to be sexually active, females were more likely to have knowledge of EC use compared to males. The study underscores the need to increase awareness regarding EC among University students in order to offer them the opportunity that EC provides if other forms of contraceptives are missed. Keywords Emergency contraceptives Ghana Knowledge Usage University students
& Eugene Kofuor Maafo Darteh [email protected] David Teye Doku [email protected] 1
Department of Population and Health, University of Cape Coast, Private Mail Bag, Cape Coast, Ghana
Background Unwanted pregnancy and its related health problems such as maternal and infant mortality resulting from unsafe abortion is a global public health problem. Globally, it is estimated that 44 million pregnancies end in abortion each year [1]. Estimates suggest that in 2008, one in five pregnancies ended in abortion and nearly half of these abortions were unsafe [2]. These estimates vary by region. Although Africa has lower abortion rates compared to Latin America, the percentage of unsafe abortion of 97 % is staggering; especially in Western Africa where available data indicate that nearly all abortions were unsafe [2]. Contraceptive use is an important strategy for the prevention of unwanted pregnancy and avoidance of induced abortion. In developing countries where there is high fertility rate, contraceptive use is also important for controlling population growth in order to ensure qualitative human and socioeconomic development. Cleland et al. [3] indicate that contraceptive use in developing countries has reduced the number of maternal mortality by 44 % which is about 270,000 deaths prevented in 2008 but could prevent 73 % if the full demand for birth control were met. Contraceptive is therefore critical in achieving the UN Millennium Development Goal 5 (MDG 5); to reduce maternal mortality and achieve universal access to reproductive health. Ghana’s population continues to rise at an alarming growth rate of about 3 % according to Population and Housing Census [4]. The most recent national data available on contraceptives indicate that although there is high knowledge about contraceptives, the usage is low [5]. Among married women 15–49 currently using any method and any modern method of contraceptive were 24 and 17 %, respectively from 2003 to 2008 [5].
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J Community Health
Ghana formulated a national family planning policy already in the mid 1960s. The goal of the policy among other things was to initiate programmes that will help reduce the high total fertility rate of over 5, particularly, through increased contraceptive use. Despite this effort, the total fertility rate of Ghana is 4.4 [5]. The use of emergency contraceptive (EC), to prevent pregnancy within 72 h after unprotected sexual intercourse, in particular, offers women who are not on regular conceptive a last resort to prevent unintended pregnancy and its related health issues. Numerous studies have been conducted on the knowledge of university students on ECs in the Sub-Saharan Africa [6–10]. These studies have reported varied levels of knowledge of ECs for Nigeria (50.7 %), Uganda (45 %), Cameroon (67 %), Ethiopia (43.5 %) and South Africa (56.5 %). In Ghana, few studies have been conducted on ECs among university students [11, 12]. In their study, Addo and Tagoe-Darko [11] observed that 51 % of the students had heard of ECs. An earlier study by Baiden et al. [12], observed that 43.2 % of the 194 respondents had heard of modern EC methods with only 11.3 % indicating correctly the recommended time within which emergency contraceptive pills (ECPs) are to be taken after unprotected sex. What was missing in both studies is the determinants of students’ knowledge of ECs. This study attempts to fill the gap by examining the factors that predict university students’ knowledge and use of ECs. University students are among innovators involved in the adoption and spread of innovation in many spans of society. They are, therefore, expected to lead in both the knowledge and usage of ECs. However, we are not aware of any study on the knowledge or use of ECs among young adults in Ghana in the past decade. The goal of this study is to explore to what extent university students in Ghana have knowledge of and use ECs and explore the drivers of ECs knowledge and use.
Methods Data for the study were collected from a survey of resident students of the University of Cape Coast in Ghana. The University of Cape Coast is one of the six public (State owned) universities in Ghana. It has total population of about 24,000 pursuing various academic programmes in the field of Agriculture, Arts, Education, Physical Sciences, Social Sciences and Law and Medicine. At the time of the data collection the Faculty of Law was just in the process of admitting it maiden students and therefore the study did not include students of that Faculty. The University has 8 Halls of residence, which accommodate about 6000 residential students. The University operates a residential
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policy where all freshmen are accommodated in the traditional halls of residence while continuing students make their own arrangements for accommodation. A total of 571 students (283 males and 288 females) were randomly sampled and interviewed. Using a two-page questionnaire, information on the background characteristics of respondents, knowledge of ECs and usage of ECs were collected. Informed consent was obtained from all participants. At the time of the study no functional Institutional Review Board existed at our institution. The outcome variables used in this paper are knowledge of ECs and usage of ECs. These variables had dichotomous responses 0 = No and 1 = Yes. The explanatory variables included sex of respondents, age of respondents, age at first sex, number of sexual partners, circumstance of first sex, ethnicity and residential status. Age was grouped into 17–19, 20–24, 25–19, 30–34 and 35?. Age at first sex was grouped into less than 15, 15–19, 20–24, 25–29 and 30?. Number of sexual partners was grouped into 1, 2–3 and 4?. Residential status was divided into ‘‘resident’’ and ‘‘nonresident’’. To reflect the major religious groupings in Ghana, religion was grouped into Protestants, Catholics, Pentecostal/Charismatics, Muslims and Others. Ethnicity was categorised into Akan, Mole-Dagbani, Ewe, Ga/ Adangbe, Other Ghanaians and Non-Ghanaians. Chi square and logistic regression analysis were the statistical tools used in data analyses. The result of the logistic regression analyses are reported as odds ratios (OR) at 95 % confidence interval (CI). The Stata software was used for the data analyses.
Results Knowledge and Utilization of Emergency Contraceptives Among University Students More than two-thirds of the respondents were aged 20–24 years and about 15 % were aged 25–29 years. Twenty-nine percent of the respondents were in level 300 while 28 % were in the final year of their four year undergraduate studies. About 8 % of the students were married and the rest were not. More than half of the students interviewed were Akans with \1 % being foreign students. More than 90 % of the respondents professed one Christian faith or the other (Protestants—31 %; Catholics—22 %; Pentecostals—38 %) and 6 % were Muslims. About 56 % of the respondents were non-residents (those in the diaspora) with about 44 % being residents in the traditional halls of residence. Sixty-five percent of the respondents had ever had sexual intercourse. There was a statistically significant difference in the proportion of males and females who had ever had sex (v2 = 11.3221;
J Community Health Table 1 Background characteristics of respondents Variables
Males (N = 283)
Females (N = 288)
Total
Ages of respondents \20
Table 1 continued v
2
(N = 149)
5.790
Has a friend ever used EC
0.946
2.83
5.90
4.38
Yes
52.35
57.69
55.29
20–24
73.14
75.69
74.43
No
47.65
42.31
44.71
25–29
15.90
13.19
14.54
30–34
5.65
3.47
4.55
Yes
35.57
37.36
36.56
35?
2.47
1.74
2.10
No
64.43
62.6
63.44
Level 100
19.08
22.92
21.02
Daily
Level 200
21.91
20.14
21.02
Weekly
11.54
5.80
8.26
Level 300
28.62
29.86
29.25
Monthly
26.92
26.09
26.45
Level 400 Ever married
30.39
27.08
28.72
Occasionally
55.77
68.12
62.81
Level of education
7.77
7.99
7.88
92.23
92.01
92.12
59.72
59.03
59.37
6.01
4.51
5.25
Ethnicity Mole-Dagbani Ewe
0.114
Frequency of use
5.891 5.77
0.009
No Akan
Ever used EC
1.830
Yes
6.400
19.79
18.06
18.91
Ga Dangbe
8.13
12.15
10.16
Other Ghanaian
5.30
6.25
5.78
Non-Ghanaian
1.06
0.00
0.53
Religion
0.00
N = 52
N = 69
2.48
N = 121
When is EC supposed to be used Anytime after sex
50.00
34.78
41.32
Within 48 h after sex during ovulation
38.46
60.87
51.24
Others
11.54
4.35
7.44
29.05
38.46
34.24
Preferred source of EC Clinic/hospital 3.409
5.738
Health worker
11.49
9.89
10.61
Chemist/drug store
46.62
45.05
45.76
30.39
32.64
31.52
Others
7.43
3.85
5.45
Catholic
24.03
20.14
22.07
Don’t know
5.41
2.75
3.94
Pentecostal
39.58
38.19
38.88
5.30 0.71
7.29 1.74
6.30 1.23
Non-resident
55.48
55.90
55.69
Resident
44.52
44.10
44.31
Yes
72.08
58.68
65.32
No
27.92
41.32
34.68
Yes
51.59
62.50
57.09
No
48.41
37.50
42.91
(N = 146)
(N = 180)
(N = 326)
Residential status
Source: Fieldwork, 2013 0.0105
Ever had sex
11.3221***
Ever heard of EC
6.935**
Source of information on EC
v2 3.4713
Radio
45.89
43.33
44.48
Health worker
15.75
17.22
16.56
Peer educators
4.11
7.22
5.83
Friends
24.66
26.67
25.77
Others
9.59
5.56
7.36
v2 6.629**
Protestant
Moslem Others
v2
(N = 182) (N = 331)
p \ .001). Fifty-seven percent of the respondents had ever heard of ECs while the rest had never heard of them. Also, there was a significant difference in the proportion of males and females who had ever heard ECs (v2 = 6.935; p \ .05) (see Table 1). Among those who had ever heard of ECs, 44 % indicated that their source of information was the radio while 26 % indicated that their source of information was friends. Fifty-five percent of the respondents knew a friend who had ever used ECs. More than a third of the respondents had ever used an EC, and more than 60 % indicated that they used ECs occasionally while 26 % used it monthly. With regards to when the contraceptive is supposed to be used, 51 % indicated that it should be used within 48 h of after sex during ovulation with 41 % indicating that it should be used anytime after sexual intercourse. There was a statistically significant difference in the respondents’ knowledge regarding when ECs are to be used. More than 45 % of the students considered
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J Community Health Table 2 Logistic regression model showing the relationship between socio-demographic factors and knowledge of ECs
Predictors
Model 1 OR
95 % CI
Model 2 OR
95 % CI
Sex of respondent Male
Ref
Female
1.564**
Ref 1.120–2.183
2.804***
1.688–4.658
Age groups 17–19
Ref
20–24
2.22
0.959–5.136
Ref 3.961
25–29
3.492**
1.371–8.894
4.234
0.810–22.130
30–34
2.844
0.913–8.861
3.711
0.608–22.630
35?
8.889**
1.585–49.833
11.778**
1.193–116.281
\15 15–19
Ref 0.749
0.230–2.440
Ref 0.543
0.150–1.968
20–24
0.642
0.194–2.130
0.514
0.140–1.891
25–29
0.606
0.131–2.792
0.296
0.050–1.762
30?
0.485
0.074–3.191
0.216
0.025–1.872
0.829–18.911
Age at first sex
Number of sexual partners 1
Ref
02–3
0.992
0.611–1.611
Ref 1.25
0.731–2.136
4?
2.598
0.956–7.057
3.634**
1.224–10.786
Was first sex planned Planned
Ref
Just happened
0.703
.447–1.103
Ref 0.644
0.394–1.051
Forced
1.105
.432–2.827
0.973
0.338–2.802
Residential status Resident
Ref
Non-resident
0.677**
Religion Protestant
Ref 0.485–0.946
Ref
0.913
0.570–1.463
Ref
Catholic
1.423
0.892–2.269
1.029
0.517–2.049
Pentecostal
1.074
0.723–1.595
0.784
0.443–1.389
Moslem
0.732
0.357–1.499
0.468
0.156–1.400
Others
1.091
0.237–5.015
0.336
0.061–1.847
Ethnicity Akan
Ref
Ref
Mole-Dagbani
1.664
0.757–3.663
2.266
0.699–7.343
Ewe
1.211
0.780–1.879
1.063
0.581–1.947
Ga/Dangme
1.467
0.824–2.611
1.193
0.539–2.640
Other Ghanaian
0.999
0.824–2.611
0.853
0.259–2.810
Non Ghanaian
1.66487
0.149–18.535
1.294
0.882–18.987
Source: Fieldwork, 2013 *** p \ .001; ** p \ .05; * p \ .10
chemical/drug stores as their preferred source of the ECs with 34 % indicating that they preferred clinics/hospitals. Multivariate Results Bi-nomial logistic regression was used to examine the determinants of students’ knowledge of EC methods. The
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results show that there was a significant relationship between sex and knowledge of ECs. For instance, females were 2.8 times more likely to know of EC methods compared to males (reference) (p \ .001). Age was significantly related to knowledge of ECs with the odds highest among those aged 35 years and above compared to those aged 17–19 years (p \ .001). A significant relationship was
J Community Health Table 3 Logistic regression model showing the relationship between socio-demographic factors and use of ECs
Predictors
Model 1 OR
95 % CI
OR
95 % CI
Sex of respondent Male
Ref
Ref
Female
1.0804
1.856**
1.024–3.364
Age groups 17–19
Ref
20–24
4.335
0.533–35.25
3.772
Ref 0.290–49.009
25–29
5.091
0.672–49.205
4.14
0.300–57.164
30–34
5.091
0.518–50.004
4.448
0.271–72.933
35?
12.00**
1.057–136.793
10.532
0.559–198.219
\15 15–19
Ref 1.106
0.340–3.598
Ref 0.758
0.210–2.730
20–24
0.7
0.208–2.350
0.496
0.133–1.840
25–29
0.25
0.036–1.703
0.122
0.013–1.120
30?
0.333
0.026–4.186
0.142
0.008–2.370
Age at first sex
Number of sexual partners 1
Ref
02–3
1.383
0.783–2.445
1.664
Ref 0.868–3.191
4?
1.826
0.765–4.359
1.968
0.729–5.309
Was first sex planned Planned
Ref
Just happened
0.569**
0.337–0.959
0.495
Ref 0.280–0.876
Forced
0.604
0.225–1.620
0.432
0.150–1.245
0.634–1.578
1.257
Residential status Resident
Ref
Non-resident
1.001
Religion Protestant
Ref
Ref
0.718–2.200
Ref
Catholic
0.975
0.533–1.785
0.998
0.468–2.124
Pentecostal
0.868
0.504–1.495
0.858
0.445–1.653
Moslem
0.691
0.226–2.113
0.624
0.137–2.843
Others
?
?
Ref
Ref
Ethnicity Akan Mole-Dagbani
1.585
0.625–4.022
0.904
0.268–3.055
Ewe
1.428
0.804–2.534
1.435
0.692–2.973
Ga/Dangme
1.049
0.501–2.198
0.864
0.367–2.034
Other Ghanaian
0.969
0.347–2.701
1.635
0.325–8.244
Non Ghanaian
1.937
0.119–31.487
1.269
0.065–24.819
? omitted *** p \ .001; ** p \ .05
observed between number of sexual partners and knowledge of ECs with students with 4 or more partners being 3.6 times more likely to know of ECs compared to those with a partner (p \ .05) (Table 2). A bi-nomial logistic regression was also used to examine the relationship between socio-demographic characteristics
and use of ECs among the respondents. Results in the Table 3 show that there was a significant relationship between sex of respondents and decision to use ECs. For instance, females were more likely to take decisions regarding the use of ECs compared to males (OR = 1.8; p \ .05) (Table 3).
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J Community Health
Discussion More than half (65 %) of the University of Cape Coast students reported being sexually active. This is higher than those found among Ethiopian students [13] and in a number of African countries [14]. Majority of male students (72 %) were sexually active compared to 59 % of female students. The common sources of information on EC were radio (44 %) and friends (25 %). This study suggests that knowledge of EC use was low among the University of Cape Coast students, although majority were sexually experienced. This finding is comparable with those found among university student in Durban, South Africa [10] but lower than those found in Cameroon [8] and higher than those reported among Ghana students in 2009 [11], in Nigerian students [6], Ugandan students [7] and Ethiopian University students [9]. Interestingly, although males were more likely to be sexually active, females were more likely to have knowledge of EC use compared to males. Available literature suggests that gender disparities exist with respect to reproductive health among young people to the detriment of females [15, 16]. Already at young age males tend to exert their masculine influence on their female counterparts with respect to reproductive health decision-making. This influence expands over the use of contraceptives, abortion and sexual activity. Male adolescents also favour and encourage male sexual initiation among young males but frown on it among young females. The desire to prevent losing their partners may hinder young females from making informed reproductive health decisions while the quest to keep sexual relationship secret may contribute to young people (both males and females) unwillingness to utilize reproductive health services even where they are available. Females are most likely to suffer most of the burden of unwanted pregnancy than males and are therefore most likely to be concerned about contraceptive use including ECs. Also in a typical African setting, females are the primary target of reproductive health education rather than males. These issues could explain the gender differences found in the knowledge of EC use in this study. We expect University students to be among the innovators with respect to the experimentation and usage of products such as ECs, which is not very popular in Ghana, for example, in the Ghana Demographic and Health Survey EC was rarely mentioned as a contraceptive method [5]. Therefore, the relatively low usage of ECs found in this study suggests the need for awareness creation among the youth regarding this available ‘‘last chance’’ option of contraception.
Conclusion Although most of the respondents were sexually active, knowledge of EC as well as it use was relatively low among them. The low level of EC use is consistent was
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finding from Senegal [17] and elsewhere [8, 10]. More male students were sexually active than female students. However, knowledge of EC use was higher among female students than their male counterparts. The study underscores the need to increase awareness regarding EC among university students in other to offer them the opportunity that EC offers if other forms of contraception are missed. The radio and friends can be some of the important sources for such a campaign.
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