Awareness and Utilization of Emergency Contraception Among Female High School Students in Southeast Ethiopia

To assess awareness and utilization of emergency contraception and associated factors among female high school students in Oromia regional state, Ethiopia. A cross- sectional


Background
Emergency contraception (EC) is contraceptive methods that can be used by women within five days following unprotected intercourse to prevent an unplanned pregnancy.EC provide a unique opportunity for preventing pregnancy after unprotected sex that no other contraceptive method can provide. It is as effective as 75-99% if taken within recommended time frame [1]. The capability of EC addressing the problems of unintended pregnancy in adolescent and young people posits the service one of the most crucial remedies in contraceptive arena for the fact that the sexual activity during adolescence is usually infrequent, unplanned and unprotected [1,2]. Moreover, the steady increase in school attendance rates in developing countries has given the chance for large proportion of young people to become sexually mature while they are at secondary school or earlier. When unintended pregnancy occurred to young girls they forced to dropout from school or goes for unsafe abortion [3]. In connection to the magnitude of the problems, nearly 210 million pregnancies occur each year globally. About 40% of these pregnancies were unintended. Of these unintended pregnancies 50% ended in abortion. About 42 million induced abortions each year, nearly 20 million abortions are unsafe. This represents 13% of maternal death. More than 95% of unsafe abortions occur in developing countries and nearly half of maternal deaths in sub-Saharan Africa were due to unsafe abortion [4,5]. In most developing countries complication of pregnancy and childbirth are a leading cause of death and disability among women of reproductive age. Teenage girls are at double risk of dying from pregnancy and birth complication than women over 20 years. This risk is five times higher for those girls under 15. In sub-Saharan Africa nearly 60 % of women who have unsafe abortion are younger than 25years of age, and 25% are teenagers [5,6]. Of the respondents who had heard about emergency contraception only 15.4% of them made use of it. A study conducted and significant proportions of it are manipulated unsafely. Teen age girls in developing nations including Ethiopia are at increased risks. The situation is worse in the developing countries like Ethiopia and much worse in rural and sub urban areas. However, the gap in information has been affecting the interventions. Therefore, this study is conducted with the aim to assess the awareness and utilization of emergency contraception and associated factors among female high school students' south-east of the Oromia region, Ethiopia. The study employed a cross-sectional quantitative using stratified random sampling technique. The overall data management and processing used sound statistical software for this purpose. Appropriate statistics were used to reveal statistical associations of related variables to the emergence contraception awareness and utilization. Ninety three percent of the study participants completed the questioners correctly. More than half of the respondent were in the age range between 13-15 years with the mean age of 15.46(SD +/-Majority of the study participants were from Oromo ethnic group. Less than half of the respondents had ever heard the existence of emergency contraceptives. Small proportions of sexually active respondents had used it. The study indicated that awareness and use of emergency contraceptives increase with age and level of education both the students and that of the mothers. The study revealed that awareness and utilization of emergency contraceptives is low. This leads to increased risk of unintended pregnancy and unsafe abortion. Therefore, the study recommends all concerned bodies should take parts in designing programs which increase the awareness and utilization of EC among high school students. in Jimma town, south west Ethiopia among female high school students revealed that (40.5%) had heard about EC. From those who heard of EC, 27% of the respondents mentioned the correct recommended timing for oral pills of emergency contraception [8][9][10][11]. Currently, there are more adolescent girls in school than ever in our country. It is imperative that these girls have to complete their secondary education and beyond without any risk of unwanted pregnancies. EC is one of the known contraceptive methods to avert such problem. Knowing the level of awareness and utilization of EC by school adolescents is the first step of all the intervention to be implemented to protect adolescents from unintended pregnancy.
Though few studies have been conducted on EC, they were focused only on students of higher institutions in big cities of the country.
However, there are few or no scientific based research has been conducted so far in a district town like Dodola in which students come from both the town and rural areas around it. Thus, this study was conducted with an intention to determine awareness and utilization of EC and factors affecting the awareness and utilization of EC among Dodola female high school students. The study finding aimed to shape the local intervention by equipping district and zonal health leaders and service providers. Furthermore, the finding of the study will enable the comparison of service utilization within the region and outside; hence area specific interventions can be planned.

Study Setting
Dodola is located in southern part of Ethiopia, Oromia national regional state, west Arsi Zone at distance of 320km from the capital city Addis Ababa and 75km from Shashemene, the zonal center. According to 2014\15 woreda base plan, Dodola has total population 30,238 of which 14,917 males and 15,321 females. There are two administrative kebeles. With respect to some social services, the town has one district hospital and two health posts owned by the government. Moreover, it has one higher, four medium, six lower clinics, one pharmacy and eleven drug stores owned privately. There are three elementary, one high school and one preparatory public school.

Study Design
The study employed an institutional based cross-sectional quantitative study design with internal comparison carried out among female high school students in Dodola town, Oromia regional state in January 2016.

Population Source Population:
The source population of the study includes all high school female students in Dodola town who were enrolled in 2015/16 academic year.

Study Population:
The Study populations were female high school students which were randomly selected for the study from both high schools in the town.

Sample Size
The sample size was determined using the following assumptions: for the first study objective, expected prevalence of level of awareness of EC (64.48%) [12], Level of confidence 95%, and 5% margin of error (d=0.05). Formula for calculating the sample size n= [(Ζ 2) ×P (1 -P)/D2]. Considering design effect of 1.5 and using correction formula for finite population (N=1123female students) by adding nonresponse rate of 10% the final sample size=395. Following similar assumption and formula by taking the prevalence of EC utilization to be (25%) [11] sample size for the second objective was 344. However, when adjusted for sexually active students, the sample size increased to 773. By comparing two sample sizes, the largest 773 was taken as final sample size to ensure the maximum sample size (Figure 1).

Sampling Technique
The schools were stratified in grade levels (9th& 10th).
Respondents from each section were selected by simple random sampling using school enrollment list as sampling frame.
Proportional distribution of sample was assigned to the respective schools, grades and sections based on the enrolment data for the academic year ( Figure 2).

Data Collection Procedure & Quality Management
The data collection instrument was an anonymous selfadministered structured questionnaire. The questionnaires initially prepared in English and translated to Afan Oromo, and again back to English to ensure consistency and validity by language experts.
Five percent of the samples were pretested before the actual data collection and some questions were amended. Training was given for data collection facilitators and supervisors for two days before the pretest and for a day after the pretest. The questionnaires were distributed to randomly selected students. Once the students finished filling the self-administered questionnaires, they had deposited them in a designated box, as informed earlier, to assure their anonymity. The overall data collection process was supervised by Principal investigator.

Data Processing and Analysis
The collected data ware checked for their completeness and consistency and entered into SPSS version 20 for analysis. Data was summarized and organized using appropriate descriptive measures; frequencies and percentages of the responses were calculated. Associations between variables were assessed by using Odds Ratio with 95% Confidence Interval. First all variables were analyzed with bivariate analysis, then variables with p-value less than 0.25 were considered in Multivariate logistic-regression.
Statistical association was declared at p-value less than 0.05 both in Bivariate and Multivariate logistic-regression.

Socio-Demographic Characteristics of the Study Population
Seven hundred nineteen of the total 773 school adolescents were completed the survey questionnaire. Fifty four (6.98%) of the questionnaire were discarded due to incompleteness. Majority

Utilization of Emergency Contraceptive
From the total 275 sexually active students only 27(9.8%) of them had used EC. Oral pill was the only methods utilized as EC.
About 21(77.8%) of users took the first dose within 72hours after unprotected sexual intercourse and 17(63%) of them were recommended to use EC by their female friends. More than eighty five percent of EC users had used it two and more times. (Table 2).   and unsafe abortion in this study than the above two studies may be due to high awareness and utilization of EC in those studies than current one which is 70% for Dessie and 90.3% for Mekele [9,13]. When compared to Dodola, the small rural town, the former two cities are with relative better positions both in health service accessibilities and information dissemination. This is more or less similar with studies of Addis Ababa University students 43.5% and high school students of Jimma town 40.5% [11,14]. But it is lower than those studies conducted among tertiary students in Nigeria, college students of Dessie town and Adewa preparatory students 65.3%,69.9%&64.48% respectively [9,13,15]. This discrepancy could be due to socio-demographic and difference in the education status of the study population.
This study revealed that, out of sexually active respondents only 9.8% of them were utilized emergency contraceptive methods. It is more or less similar with research done among youths of Parbat district, Nepal 8.34% [10]. This study found that respondents who had constant pocket money were more than three times more likely to practice EC than those who had no pocket money. This may be explained by having constant pocket money may help students to decide by themselves to buy and use EC if they faced unprotected sexual intercourse without the consent of others. Moreover, the more they are financial sufficient, the more that they have freedom to practice sex. This is in agreement with the study conducted in Hawassa University about the patterns of risky sexual practice among students [18].

Conclusion and Recommendation
The study finding showed low awareness and utilization of emergency contraceptive among female high school students. This may be among the reasons for high rate of unintended pregnancy and unsafe abortion among the study population. Awareness and utilization of female high school students on EC are affected by a range of circumstances. Given the high rate of unintended pregnancy and unsafe abortion reported by the study participants; the academic institution with the health sector should take measures that can increase awareness of students and ensure easy availability of EC at school level or adolescent and youth friendly clinic in the nearby.

Acknowledgement
We would like to thank school of public and environmental health, College of medicine and health sciences, Hawassa University for technical and financial support. We also would like to extend our gratitude to Dodola town education office, school principals, teachers, data collection facilitators, supervisors and study participants for their invaluable assistance and participation during the study period.

Ethical Considerations
Ethical clearance was obtained from Hawassa University, College of Medicine and Health sciences Institutional Review Board (IRB). Official letter from Hawassa University was submitted to Dodola town educational office and high school's administrators.
Informed verbal consent was obtained from the study participants after detail explanation of the purpose and the benefit of the study.
Participants were informed that they have full right to discontinue or refuse to participate in the study at any time in the continuum of the data collection. They were also informed the anonymity of the study that by any means their participation in the study and response shall remain confidential.

Consent for the Publication
This manuscript is an extract from the MPH thesis. All ethical issues including communication of the finding to various stakeholders were properly communicated and their consents were obtained verbally.

Data Availability
The data for this study will be available when needed from the SPSS data pool.

Declaration of Funding
As mentioned earlier, this study was part of the fulfillment for the requirement for the master's degree in public health; small proportion of fund received from Hawassa University and the other portions of expenses were covered by me in support from my family and friend.

Competing Interest
The manuscript is part of an MPH thesis. It was the efforts of both authors mainly dedicated for academic purpose. Since the