Exploring barriers to long-acting reversible contraceptive utilization among the pastoralist women in southern Ethiopia: Qualitative study approach, 2024

Study design and participants

A qualitative descriptive study design with a qualitative research approach was employed for this study. The study employed thirty-three pastoralist women aged (15–49 years) who were purposefully sampled from three pastoral districts for focus group discussion. Only married women were included. Four family planning coordinators, four religious leaders and four community figures were included in the key informant interviews.

Procedures

The interviews were conducted by health workers with experience in qualitative research methods. The number of FGDs was determined on the basis of the principles of saturation of information. Every member of the group contributed to any question asked before proceeding to another question. Married discussants representing different backgrounds in terms of gender, profession, education, and social status were included in the study. The IDIs were performed among well-known people in the community and included community figures, religious leaders and healthcare providers. The participants were interviewed, and their opinions about LARC and key barriers to its use were discussed. A semi structured interview aided by audio tape was conducted. The primary researcher led the interviews following a semi structured interview guide developed from the literature review^15–17 with the flexibility to explore topics as they arose. One facilitator facilitated the interview process. The interviews began with thirteen interview guide questions designed to explore participants’ opinions, followed by broader discussion among the group and suggestions. The interviews were audio recorded and transcribed verbatim. Data from the field notes were reviewed and verified by the participants. When transcribing, square brackets were used to denote nonverbal activities, and names or places were removed and replaced with non-identifying letters. The discussion was performed in the Afan Oromo language as preferred by the discussants and later translated into English during the transcript, with each FGD lasting for 60–90 minutes and the IDI lasting for 30–45 minutes.

Trustworthiness

To determine the accuracy and reliability of the data, the criteria of credibility, transferability, dependability, and confirmability were considered.¹⁵

Data analysis

The interview transcripts and field notes were analyzed through principles of inductive thematic analysis using systematic approach. The data collected from the focus groups and interviews were transcribed verbatim. First, the principal investigator transcribed verbatim, generated codes and themes, and then reviewed, interpreted, and described these codes and themes.¹⁷ Other members of the research team analyzed the codes and themes, making adjustments and consolidating them as needed. The analytical process worked toward condensing the ideas to the point where key ideas were defined, described here as themes. Data analysis began while further interviews were being conducted; recruitment ceased when thematic saturation was reached. An independent researcher fluent in both Oromic and English reviewed the transcripts for accuracy and original meaning preservation during translation.

Ethical considerations

Ethical clearance was received from the Institutional Review Board (IRB) of Bule Hora University on March- 28/2024 with protocol number of 028/24/IHSGS. The study was conducted from March 30 to April 25, 2024. Married couples were notified of the purpose of the study as it attempt to improve knowledge and attitudes about family planning and contraception methods. This study obtained both verbal and written informed consent, which was approved by the Bule Hora University IRB committee. As a result, each study participant who could not read or write provided verbal consent, while literate participants provided written informed consent before to participating in the study.

Sociodemographic profiles of the study participants

In this study, the researcher enrolled a total of 46 participants: 33 reproductive age groups for the FGD and 12 key informants for the IDI (4 family planning coordinators, 4 religious leaders and 4 community figures). The mean age of the study participants was 29.5 years (range 18–47 years) ( Table 1).

Barriers to long-acting reversible contraceptive utilization among pastoral communities in southern Ethiopia

Emerged themes

Five themes emerged from the analysis of the client’s focus group discussion and key informant interview data on barriers to long-acting reversible contraception utilization in pastoral communities.

Theme 1: Perceived myths and misconceptions

Subtheme 1.1: Perceived side effects (cancer, infertility, heavy and sudden bleeding, overweight, tininess, headache and stress): Some women never use contraception methods because of concerns about side effects. However, other women utilized FPs but discontinued them because of side effects. Almost all women reported bleeding as a major side effect of LARC. Some had personal encounters with adverse effects, whereas others were concerned with a rumor. When women were asked about the side effects of using LARCs, they stated the following:

On the other hand, some women experienced adverse effects and changed methods. Many women preferred long-acting reversible family planning over short-acting methods. When asked which methods are most acceptable to their bodies, two participants responded as follows:

Furthermore, some women noted that the adverse effects differ from one woman to another. They described their opinion as follows.

Some participants associated LARC use with cancer and infertility. One woman was diagnosed with cancer after receiving LARC. The health professional did not inform her that the cancer was caused by the use of contraception. However, she had directly linked the cancer to the use of contraception. Another religious leader revealed his wife’s experiences with LARC use. He stated that his wife was unable to conceive again following the removal of the LARC. They expressed their viewpoint as follows:

Subtheme 1.2: FP is not appropriate for women who travel long distances: The women asserted that pastoral women travel long distances to find water and collect firewood. When asked about the barriers to FP use, particularly for pastoral women, two expressed their thoughts as follows:

Subtheme 1.3: FP is not suitable for women who work intensively and carry heavy objects: The women indicated that pastoral women carry heavy objects, such as grain, wood, and water, on their backs. Bleeding occurs suddenly during outdoor activities. When asked about the obstacles to FP use, particularly for pastoral women, the participants expressed their opinions as follows:

Theme 2. Access issues: Some respondents highlighted the distance between health facilities and the need for frequent contact to receive services as barriers to FP utilization. When asked about pastoral women’s obstacles in accessing FP health services:

Theme 3: Desire to have many children

Subtheme 3.1: Children are wealth: Many participants believe that having children is a sign of wealth. They believe that a family with many children might gain respect from the neighborhood and even provoke fear toward that family. This intention makes it possible for them to desire to have many children. They stated their opinion as follows:

Another participant argued that children are not riches, which is opposed to the aforementioned notion. According to them, a person should have children in accordance with his or her standards of living and be in charge of the children’s clothing, food, and education. The following is how these participants expressed their opinions:

Subtheme 3.2: Children are gifts of God: The participants strongly believe that children are God’s gifts. Some participants stated that while children are God’s gifts, they should be planned. Others, however, believe that preventing God’s gifts through the use of medications such as FP is sinful. They expressed their suggestions as follows:

Theme 4: Religious belief: Religion was one of the sociocultural issues identified as barriers to LARC utilization by participants from various perspectives. Some participants believe that the Bible does not oppose FP, whereas others believe that it does not support FP. When asked about sociocultural barriers to LARC utilization, several participants expressed their views as follows:

Theme 5: Husband objection. Husband approval is a crucial factor in women’s FP usage. Some husbands encourage their wives to use FP, whereas others oppose it. When the women were asked about their spouses’ support for FP utilization, they expressed their opinions as follows:

The data has been coded and categorized into five main themes emerged from the analysis of the client’s focus group discussion and key informant interview data on barriers to long-acting reversible contraception utilization in pastoral communities: Perceived myth and misconception, distance of health facility, desire to have many children, religious belief and husband’s objection ( Table 2).

Conclusion

This study revealed that there are widespread beliefs and misconceptions concerning long-acting reversible contraceptive use among pastoralist women. In this study, there are many barriers to LARC use, including myth and misconception (perceived side effects, FP is not suitable for women who work intensively, carry heavy objects, and travel long distances), the desire to have many children (children are wealth and God’s gifts), religious beliefs, and the husband’s objection.

Recommendation

Information education communication should be provided to address myths and misconceptions about the LARC during the FP intervention for pastoralist women via HEW, HCP, media, and community education. In addition, there is a need to enhance social opportunities by involving religious leaders and partners in decision-making. This could be accomplished by providing health information and counseling to religious leaders and couples in the community through health extension workers. It is critical to improve their understanding and correct misconceptions, particularly with respect to perceived side effects. LARC services should be integrated into other health services and delivered on a continual basis via a produced national standard manual and trained health care personnel. As myths and misconceptions about LARC use emanate from a variety of concerns, this study may not cover all of them; therefore, future research is needed to investigate additional myths and misconceptions concerning contraception use.