This study was conducted in three pastoral districts of the West Guji Zone, southern Oromia, Ethiopia. It is found at distances of 570 km from Addis Ababa, the capital city of Ethiopia. The zone was established by nine districts and two city administrations. The total number of reproductive-aged women living in the West Guji Zone was 199543. The zone has three primary hospitals and one teaching hospital. This study was conducted from 10/02/2023-02/04/2024.

A community-based cross-sectional study was conducted. All married women of reproductive age who resided in a randomly selected kebele (small administrative unit) and lived in the study area for the last six months as a resident were included in the study, while those respondents who reported having infertility or severe illness and who were unable to respond during the study time and who resided in the study areas for less than 6 months were excluded from the study.

The sample size was calculated using the single population proportion formula by taking into account the following assumptions: at the 95% confidence level, 5% margin of error (d) between the sample and population parameters, and the overall prevalence (p) of LARC utilization was 33.4% ¹⁵ according to previous studies. N = Z α / 2 2 * p * ( 1 − p ) / d 2

Where Z _α/2 is the critical value of the normal distribution at α/2, d is the margin of error, P is the sample proportion, and N is the sample size. After adding 10% of the possible nonresponse rate, the final sample size computed is 376.

There are a total of 9 districts and one city administration in the West Guji zone. Among the 9 districts and one city administration, three districts are categorized as pastoralist districts. This study included all three pastoral districts (Dugda Dawa, Surro Barbuda, and Malka Soda). First, from the 27 kebeles of three pastoral districts, 12 kebeles were selected by lottery methods, four of which were from each district. Then, 376 calculated sample size were assigned to the respective kebeles using a proportional allocation based on their number of reproductive age group women. Before actual data collection, the number of women in the reproductive age group was obtained from the district health office before actual data collection. The interval was estimated (k=2), and eligible women of reproductive age were selected through a systematic random sampling procedure. The lottery method was used to select one woman to be included in the study in households with more than one eligible woman.

Six midwives with a diplomas were recruited for data collection, and two public health officers were recruited to supervise and facilitate the data collection process. The questionnaire was adapted from different literature ^{15– 17} and first formulated in English and then translated into the regional working language, Afan Oromo, and back-translated to English to check its consistency by language experts in both languages. The questionnaire comprised a total of 52 questions arranged in 7 sections. The first section is composed of 4 questions to assess the location of the study participants. The second section is composed of 14 questions to assess the socioeconomic and demographic characteristics of the respondents. The third section is composed of 8 questions to assess respondents’ housing conditions. The fourth and fifth sections comprised 12 questions to assess the knowledge and attitudes of the study participants regarding LARC. The knowledge part comprised dichotomous questions (true or false) to assess the participant’s knowledge of LARCs. The following knowledge items questions were used to assess the knowledge of participants: - 1. The IUCD is not appropriate for females at high risk of contracting sexually transmitted infections. 2. Preventing pregnancy for 5 years; 3. The IUCD has no interference with sexual intercourse or desire; 4. Long-acting reversible contraceptives are immediately reversible; 5. The IUCD can prevent pregnancies for more than 10 years; 6. Insertion and removal of implants require minor surgical procedures)

The attitude section is composed of trichotomies’ questions (agree, not sure, and not agree). The following attitude items questions were used to assess participants’ attitudes: - 1. The utilization of long-acting reversible contraceptives imposes restrictions on routine daily activities. It is shameful that privacy is lost during intrauterine contraceptive device insertion. The use of implants or the IUCD can store blood in the abdomen and cause cancer. The utilization of implants may result in substantial and irregular monthly hemorrhages; 5. The insertion and removal of the IUCD is extremely painful. The use of long-acting reversible contraceptives requires adequate nutrition. The sixth and seventh sections of the study are composed of 17 questions that assess the study participants reproductive factors and client- and service-related factors.

The participants’ knowledge was assessed by the total number of correct answers to six items on knowledge questions, with a minimum score of 0 and a maximum score of 1. The participants’ knowledge was measured by the total number of correct answers to six items on knowledge. A score of 1 was assigned to every correct response, whereas a score of zero was assigned to an incorrect response. Knowledge questions were scored and combined, and the mean score was computed to determine the participants’ overall knowledge. The mean knowledge score was classified into the percentiles of poor, moderate and good knowledge. ⁷ Similarly, the participants’ attitudes were measured by the total number six items, with a minimum score of 1 and a maximum score of three. This was measured using six items on a 3-point Likert-type scale (1= agree, 2=not sure, 3= not agree) computed and combined, and the mean score was computed to determine the overall attitudes of participants. The mean attitude score was classified into percentiles of negative, moderate and positive attitudes. ^{7, 12}

All documented questionnaires were checked for completeness, consistency, and accuracy. The data were entered into Epi-Data version 4.6 ¹⁸ and exported to SPSS version 25 statistical software for further analysis. ¹⁹ Descriptive analyses (frequency, mean, percentage) were carried out for exposure variables. Ordinal logistic regression was used to determine the relationship between the outcome and each independent variable. The odds ratio and 95% confidence interval were estimated to specify factors associated with the outcome variable. The level of statistical significance was indicated by a p value less than 0.05 in the model. The results were presented in tables, graphs, and text.

Ethical information was obtained from the Bule Hora University Ethical Review (ERC) Board. Ethical Review Committee Decision: Meeting No: 2/2024: Protocol number: 025/24/IHSGS Ref.no. BHU-IOH 02-012 Review Date: February- 14/2024. The purpose of the study was explained to the study participants that the study is an attempt to improve knowledge and attitudes about family planning and contraception methods, and written and verbal informed consent was obtained from each participant. The research was conducted according to the Declaration of Helsinki.

A total of 376 participants were included in this study with a response rate of 100%. About 163 (43.40%) were urban residents, while 213 (56.60%) were rural residents. Seventy-one (18.90%) respondents completed grades 9-10+, while 122 (32.40%) did not attend any school. The majority, 354 (94.20%) of the women, were housewives, and 125 (33.20%) were poor ( Table 1).

Among the 376 study participants, 42 (11.80%) women were primigravida, while 121 (34.00%) were multigravida with more than five living children. The majority, 218 (58.00%) women, had not planned for their last pregnancy. Among the 233 (62.00%) women who had ANC for their last pregnancy, 139 (37.00%) obtained family planning counseling. Approximately 139 (37.00%) women discussed family planning with their partner, and 130 (34.60%) of them obtained support from their partner. The majority, 217 (57.70%), of the women delivered at home, while 149 (39.60%) delivered at a health institution ( Figure 1).

This study revealed that 54 (14.40%), 204 (54.30%) and 118 (31.40%) women had poor, moderate and good knowledge of LARCs, respectively. Accordingly, 35.60% of the participants stated that IUCD is not appropriate for females at high risk of contracting sexually transmitted infections. Similarly, 44.90% of the respondents indicated that the use of implants prevented pregnancy for 5 years, and 60.60% of respondents expressed that the IUCD did not interfere with sexual intercourse or desire ( Table 2).

An ordinal logistic regression was conducted in order to assess the association between socio-demographic characteristics and reproductive health factors with knowledge sore level.

Accordingly, having jobs, education status and having planned pregnancy were significantly associated with knowledge level score. The odds of having good knowledge about contraceptives decreased by 61% for women who had no jobs compared with their counterparts (OR: 0.39; 95% CI: 0.19, 0.79). The odds of having good knowledge decreased by 69% and 63% for women who never attended school (OR: 0.31; 95% CI: 0.10, 0.96) and completed grades 1-4 (OR: 0.37; 95% CI: 0.14, 0.95), respectively, compared to women who completed grades 9-10+. The probability of having good knowledge decreased by 59% for women with no planned pregnancy compared with women who had planned for their pregnancy (OR: 0.41; 95% CI: 0.24, 0.63) ( Table 3).

In the current study, 168 (44.70%), 120 (31.90%), and 88 (23.40%) women had negative attitudes, moderate attitudes, and positive attitudes toward LARC, respectively. About, 14% of respondents agreed that long-acting reversible contraceptives restrict normal daily activities, and 24.70% of respondents agreed that implants cause heavy, irregular monthly bleeding. Additionally, 13.60% and 47.90% of respondents confirmed that using implants or an IUCD that stores blood in the abdomen and causes cancer and the insertion and removal of the IUCD is highly painful ( Table 4).

Socio-demographic characteristics and reproductive health factors that affect attitude score level were assessed using ordinary logistic regression. Accordingly, education status, and having a history of abortion were significantly associated with knowledge level scores.

The odds of having a positive attitude toward contraceptives decreased by 78% for women who completed grades 1-4 (OR: 0.22; 95% CI: 0.06, 0.74) compared to women who completed grades 9-10+. The probability of having a positive attitude decreased by 59% for women who had no history of abortion (OR: 0.41; 95% CI: 0.21, 0.78) compared with women who had a history of abortion ( Table 5).

This study’s primary strength was the application of ordinal logistic regression, which considers cumulative probabilities rather than probabilities for discrete categories, and a community-based study design, which could help understand actual practices and related factors that impede women’s knowledge and attitudes about long-acting reversible contraceptives. However, the limitation of this study was the use of a cross-sectional study design, where it is impossible to determine a causal relationship between the outcomes and the explanatory variables. Additionally, the small sample size may have affected the generalizability of the findings.