Introduction

Family planning involves making intentional decisions about the timing and spacing of pregnancies, typically achieved through the use of contraceptive methods or voluntary sterilization, enabling individuals and couples to control the size and spacing of their families. Family planning (FP) empowers people to decide when and how many children they want to have. It plays a crucial role in accomplishing the United Nations' third Sustainable Development Goal, which aims to ensure widespread health coverage, providing all individuals with access to essential, high-quality healthcare services and safeguarding them against financial hardship and risk. Unwanted pregnancies present a health risk and incur additional medical expenses, such as those for prenatal care, delivery, postpartum care for the mother, and routine pediatric treatment for the child [1].

According to the World Health Organization, contraceptives are methods of thinking and living that are freely adopted, based on information, attitudes, and responsible decisions made by individuals and couples, to increase the health and welfare of people, families, groups, and communities [2]. This effectively contributes to the social development of a nation. Child spacing, often known as family planning, allows a couple to decide when, where, and how many children they wish to have [3]. The pill, sterilization for both genders, IUDs, injectable contraceptives, implantations, male and female condoms, diaphragms, and emergency contraception are all current means of contraception. Traditional techniques consist of intermittent abstinence, withdrawal, and folkways [4].

In underdeveloped countries, estimates indicate that 38 million young women desired to postpone becoming pregnant in 2016. Fifteen million of these young women have avoided 5.4 million unintended births by using modern contraception. 2.9 million of these pregnancies would have resulted in unsafe abortions based on current abortion rates. Furthermore, contemporary contraceptive usage prevents 3,000 maternal deaths annually in developing nations. Contraception use versus failure makes up a considerably smaller portion of unplanned pregnancies [5].

According to Bhatt et al [6], there are crucial interventions to reduce the negative health effects of family planning (FP). Such measures can reduce maternal mortality in low-income nations by 44% and can avoid 90% of abortions, 32% of maternal deaths, and 20% of pregnancy-related morbidity globally. FP lessens adolescent pregnancies, eliminates health risks associated with pregnancy, and aids in the fight against HIV/AIDS. Access to contraception encourages education, improves women’s economic standing, and progressively gives them adequate power, which leads to better health outcomes and a higher quality of life. Again Ahmed and Seid [7] said, that family planning unquestionably contributes to lowering infant mortality, improving gender equality, preventing the spread of HIV, and reducing poverty. According to research conducted by Ahmed and Seid [7] in multiple nations, access to family planning can lower newborn and child mortality by 10%, maternal deaths by as much as 40%, and maternal morbidity by 21%.

The number of unintended births would decrease by 59% from current levels of 121 million annually, better still by an estimated 6.0 million pregnancies annually if all 23 million teenage women who lack access to modern contraception received improved contraceptive services. Unwanted births wouldn't be completely prevented since some users—especially those who use condoms and other temporary techniques that depend on the users' actions—would experience contraceptive failure.

However, compared to recent heights in contraceptive use, there would be 2.1 million fewer unplanned births (62% reduction), 3.2 million fewer abortions (57% reduction), including 2.4 million fewer unsafe abortions, 700,000 fewer miscarriages of unintended pregnancies (60%), and 5,600 fewer maternal deaths associated with unintended pregnancies (71% reduction) [5].

According to a study done in Tamale Metropolis, many social stigmas in the rural villages of northern Ghana prevent most young adolescents—male and female—from using contraception. Since parenthood is valued in many countries, social pressure to have more children is thought to be one of the obstacles to contraception [4]. Similar research done in Tamale Metropolis indicated that the majority of respondents (82.9%) remain unable to openly address contraceptive issues with their parents. Unfavorable staff attitudes (60.2%), contraceptives unavailability (50.0%), travel time to medical facilities (44.9%), stigma from peers and society (48.4%), and cost of contraceptives (42.5%) were seen as obstacles to getting contraceptives. In their locality, about half of the respondents (52.1%) cannot obtain contraception [8].

Girls who become pregnant as adolescents suffer considerable negative effects on their health, education, social development, and economics. However, there is still a sizable global demand for contraception that hasn't been addressed, especially among women in sub-Saharan Africa. Young people's use of contraception is still low in Burkina Faso, where 25.1% of teenage girls between the ages of 15 and 19 are either pregnant or have children. Only 11.2% of adolescents who engage in sexual activity do so using modern methods [9].

An earlier survey in Ghana discovered that 14% of teenagers (15-19 years old) were either new mothers or expecting their first child [10]. In addition, findings from earlier studies indicate that the Northern region, including the Sagnarigu Municipality, has a high rate of teenage pregnancies. However, there are still open questions regarding sexual behavior trends, attitudes toward using contraceptives, and obstacles to using contraceptives within the Sagnarigu Municipality. As a result, the study focused on the sexual behavior of female adolescents (15–19 years old) and the reasons they believed they used or did not use modern contraception [11].

There have not been studies that identify the barriers and enablers to young people using contraceptives in the Tamale metropolitan area, which would have been used to guide both local and national policymakers on family planning. However, research on barriers and enablers to young people using contraceptives is scarce in the metropolitan, although the Metropolitan has a large proportion of children and young adults (nearly 36.4% of the population). Hence there was a need to conduct this research to assess barriers and facilitators to the uptake of contraceptives amongst youth in the Tamale Metropolis.

Methods

Study setting, design, and population

This study was a cross-sectional community-based investigation conducted in the northern Ghanaian city of Tamale. Ghana comprises 261 Metropolitan, Municipal, and District Assemblies (MMDAs), with Tamale acting as its capital. The 2021 population and housing census shows that Tamale Metropolis is home to 374,744 people, with 185,051 men and 189,693 women [12]. Savelugu Municipality shares a boundary with Tamale to the north, Yendi Municipal Assembly to the east, the Tolon District to the west, the Central Gonja District to the southwest, and the East Ganja Municipality to the south.

Study population

The study was conducted among adolescents (both males and females aged 15-24 years) in Tamale Metropolis. The research included participants aged between 15 and 24 years who willingly gave their consent to be part of the study. On the other hand, individuals below the age of 15 or above 24 were excluded. Additionally, individuals who did not reside within the Tamale Metropolis were also excluded from the study.

Sample size determination

The sample size for the quantitative study was determined using the Snedecor & Cochran [13] formula with a 95% Z-value of 1.96, estimated population proportion (p) of 0.5, and a margin of error (e) of 0.05. After calculations, the required sample size was 384.

Sampling techniques

WHO Expanded Programme on Immunization (EPI) cluster sampling technique was adopted. Although it was originally designed to estimate immunization coverage, it is also applied in community-based cross-sectional surveys. In this study, we divided the Tamale metropolis into four strata. This stratification was based on the Tamale Metropolitan Health Directorate's division of the metropolitan area for the provision of healthcare. A sampling frame of the number of communities in each stratum was created based on information from the Ghana Statistical Services, and a simple random sampling method was used to select one community for each stratum. The estimated sample size was then distributed equally among the four selected communities.

Once the communities were identified a community entry was done to explain the rationale of the study to the opinion leaders and introduced the data collectors. With the help

of the opinion leaders, the center of each community was identified. They were, however, not present during data collection.

In each community that was chosen, the trained interviewers used the EPI method to begin at a central location, where a pen was spined and a random direction was picked from that point. A home was then randomly selected among those along the line from the centre to the outside of the community. The trained interviewers entered the selected houses and if the respondents who met the criteria were present, consent was sought and the interview conducted. Where parents or significant others were present, a private place was secured within the house to conduct the interview.

Data collection tool and procedure

A designed questionnaire was used to elicit information from study respondents. The instrument was developed to cover all aspects of the specific objectives of the study. The questionnaire had four (4) sections i.e. Section A, B, and C. Section A: comprised of socio-demographic proforma which included age, currently attends school, education status, marital status, sex, religion, mother’s level of education, father’s level of education, mother’s occupation, and father’s occupation; Section B: sexual behaviors, comprised of 7 questions (multiple-choice); Section C: awareness of family planning methods, comprised of 2 questions (multiple-choice); Section D: five-point Likert scale to assess knowledge and attitude on contraceptives comprised of 12 statements; Section E: contraceptive usage and provider factors influencing usage, comprised of 10 questions (multiple-choice); Section F: five-point Likert scale to assess cultural, social, and religious factors influencing family planning usage comprised of 14 statements; Section G: five-point Likert scale to assess facilitating factors influencing family planning usage comprised of 8 statements. Before the actual data collection, permission was sought from the metropolis. The study’s purpose was explained to all respondents to ensure there was full comprehension and to rule out any form of ambiguity and both informed oral and written consent were also obtained. The questionnaires were administered to respondents by the researchers on a one-on-one basis. Each questionnaire took approximately 15-20 minutes to answer. Each questionnaire was coded for easy retrieval. The tool for the study was reviewed by health experts to ensure content validity. The reliability coefficient of the instrument was 0.90.

Data processing and analysis

The Statistical Package for Social Sciences (SPSS version 27) was utilized for analysis after the field data was imported into Microsoft Excel. Distribution tables with corresponding frequencies, percentages, means, and standard deviations were made from the descriptive data after analysis. Fisher's exact test and Chi-square test were used to assess the characteristics associated with family planning utilization. Furthermore, using binary logistic regression, a 95% confidence interval analysis of the factors influencing family planning utilization was carried out. The significance threshold was established at P value <0.05.

Results

Table 1 shows the socio-demographic characteristics of the respondents. The average age of the respondents was 20 years (SD: 2.6 years). Majority of them (n=227, 59.1%) were 20 to 24 years old, unmarried (n=328, 85.4%), enrolled in school (n=267, 69.5%), and identified as Muslims (n=291, 75.8%). Other than half of the respondents were males (n=211, 54.9%), and (n=123, 46.1%) were enrolled in secondary school. Regarding parental characteristics, the majority of respondents' mothers (n=237, 61.7%) and fathers (n=201, 52.3%) were uneducated. Only (n=38, 9.9%) of the mothers and (n=92, 24.0%) of the fathers were employed.

Table 1: Socio-demographic characteristics (N=384)

Respondents’ sexual behaviors

Table 2 shows the sexual behaviors of the respondents. Less than half (n=169, 44.0%) had ever had sex. The majority of them (n=99, 58.6%) were at least 18 years old when they had their first sex, and (n=151, 39%) reported having unprotected sex at some point. Among the 151 respondents who had unprotected sex, (n=97, 64.2%) were worried about being pregnant, (n=41, 27.2%) took drugs to prevent pregnancy, (n=28, 18.5%) got pregnant. Of those who became pregnant, (n=17, 60.7%) had the baby.

Table 2: Respondents' sexual behavior (N=384)

Awareness of family planning methods

Figure 1 shows the respondents' awareness of various FP methods. The study showed that all respondents (n=384, 100.0%) have heard about family planning. The male condom was the most popular family planning method (n=339, 88.3%) known to the respondents, followed by pills (n=232, 60.4%), female condoms (n=171, 44.5%), injectables (n=143, 37.2%), and implants (n=135, 35.2%). The family planning methods that were less known included lactation amenorrhoea (n=11, 2.9%), form or jelly (n=12, 3.1%), diaphragm (n=21, 5.5%), male sterilization (n=39, 10.2%), calendar method (n=39, 10.2%), female sterilization (n=41, 10.7%), and IUD (n=58, 15.1%).

Figure 1: Awareness of family planning methods among respondents (N=384)

Knowledge and attitude of respondents on contraceptives

Table 3 shows the respondents' knowledge of contraceptives. Overall, (n=179, 46.6%) of respondents strongly agreed that male condoms can prevent Sexually Transmitted Diseases (STDs), while (n=12, 3.1%) disagreed. A higher proportion of respondents (n=166, 43.2%) were unsure about the need for a pelvic scan before using birth control methods, and (n=90, 23.4%) strongly disagreed with the perception that contraceptive methods are only for women. Most respondents (n=108, 28.1% agreed) believed that the negative impact of contraception on health outweighed the benefits. Most respondents (n=137, 36.1%) strongly agreed that contraceptive does not guarantee 100.0% protection but the least (n=15, 3.9%) strongly disagreed. Most respondents agreed (n=146, 38.0%) that users can switch contraceptive methods if their current method is unsuitable. In addition, a greater proportion of respondents (n=186, 48.9%) agreed that contraceptives alleviate concerns about unintended pregnancies and enable women to pursue higher education (n=174, 45.3%). Nevertheless, the majority (n=128, 33.3%) believed that condoms could exert less sexual pleasure.

Table 3: Knowledge and attitude of respondents on contraceptives (N=384)

Respondents’ contraceptive usage and provider factors influencing usage

Table 4 shows the respondents' contraceptive usage and provider factors influencing usage. Approximately (n=96, 25.0%) of the respondents had used family planning services, with the majority (n=54 (56.3%) seeking these services at a pharmacy. About (n=85, 88.5%) of the respondents stated that they were successful in obtaining the family planning methods they required at the service point, and (n=78, 81.2%) expressed satisfaction with the quality of family planning services. In addition, (n=80, 83.3%) respondents considered the time spent accessing family planning services reasonable. Most of the respondents reported that service providers were friendly (n=84, 87.5%), respected their privacy (n=88, 91.7%), and provided clear and adequate information about family planning (n=77, 80.2%).

Table 4: Contraceptive usage and providers factors influencing usage among respondents (N=384)

Cultural, social, and religious factors influencing family planning usage

Table 5 shows cultural, social, and religious factors influencing family planning usage. Most of the respondents (n=112, 29.2%) strongly disagreed that contraceptive is for married and old people, and (n=104, 27.1%) strongly agreed that contraceptive before birth cause infertility. About (n=150, 39.1%) of the respondents see family planning users as prostitutes. The majority of the respondents strongly agreed that there is a lack of confidentiality and a judgmental attitude of service providers (n=150, 39.1%), and service providers has no knowledge about family planning (n=141, 36.7%). The study also showed that respondents were unsure as to whether Islam supports family planning (n=131, 34.1%) and (n=219, 57.0%) were also not sure if Christianity supports contraceptive usage.

Table 5: Cultural, social, and religious factors influencing family planning usage (N=384)

Facilitating factors influencing family planning usage

Table 6 shows facilitating factors influencing family planning usage. Around (n=125, 32.6%) of respondents said encouragement from partners/parents will increase family planning use, (n=122, 31.8%) said adequate knowledge about family planning will increase its usage, (n=116, 30.2%) said when contraceptives are sold or distributed it will increase usage, and (n=179, 46.6%) said free distribution of preferred contraceptives.

Table 6: Facilitating Factors Influencing Contraceptive Usage (N=384)

Association Between Contraceptive Usage and Socio-Demographic Characteristics

Table 7 presents the association between socio-demographic characteristics and contraceptive usage. The study revealed that there was a statistically significant association between family planning usage and respondents’ religion (p < 0.001), marital status (p=0.002), ever-had sex (p < 0.001), age at first sex (p < 0.001), mother’s level of education (p=0.028), and mother’s occupation (p=0.017).

Table 7: Association between family planning usage and socio-demographic characteristics

Predictors of family planning usage among young people

Table 8 shows the predictors of family planning usage among respondents. In the multivariate binomial logistic regression model analysis, respondents who were Christians had higher odds of family planning usage (aOR, 3.24; 95% CI, 1.47-7.14; p=0.003) than those who were Muslims. Also, respondents who had ever had sex had higher odds of family planning usage (aOR, 5.93; 95% CI, 2.34-15.03; p<0.001) than those who had never had sex.

Table 8: Predictors of family planning usage among respondents

Discussion

Less than half of respondents (44.0%) had ever had sex of which 39.3% had unprotected sex. This implies that almost all the respondents had not used protection during sexual intercourse. This shows similarity with the study from Ghana whereby 66% of the respondents had not used any form of protection at first [14]. This is dissimilar to the study from Nigeria whereby more than half of respondents (55.1%) had protected sex [15]. Also, a study from Ghana showed that out of (86.7%) who ever had sex, (66.7%) had ever used at least one form of modern contraception [16].

The current study showed that all respondents had heard about family planning and male condom (88.3%) was the most popular FP method. The state of awareness about family planning among the respondents was satisfactory. This may be because many of them were in secondary school level of education. This result is congruent with the research from Lesotho which found that awareness of contraceptives and family planning was 97.5% and the most common method known about was condoms (95.0%). The study similarly reported that most of the respondents had come to know about family planning while they were in the secondary school level of education [17]. Two other surveys in India, and Ghana showed awareness regarding family planning was high and the condom was the most popular contraceptive method among the respondents [18,19]. In contrast, cross-sectional research from Yemen revealed that the most known contraceptive method was oral pills (78.1%) [20].

According to the present study, the majority of respondents (46.6%) said that male condoms can prevent Sexually Transmitted Diseases (STDs) and agreed with the studies from Brazil and South Africa which showed that most of the respondents (53.9%, 88.7% respectively) mentioned that the condom served to prevent STDs [21, 22]. Also, the study discovered that respondents were of the view that contraceptives bring more damage than health benefits, and this was in line with the previous study from Tanzania (48.1%) [23]. Furthermore, the study revealed that most of the respondents (36.1%) said that contraceptives do not guarantee 100.0% protection, and this was in line with the study from Malaysia (54.2%) [24]. The similarities in findings may be influenced by the educational level of respondents.

The study found that only 25.0% of respondents patronized the services of family planning. This result is high but similar to the study from Tanzania (6%) [23]. Two other studies from Ghana also discovered that only 18% and 6% of respondents sought services of family planning [25]. Low usage of family planning methods leads to higher birth rates and rapid population growth. This can affect the supply of essential resources such as food, water, healthcare, education, and housing, impacting the quality of life for individuals and hindering sustainable development. Thus, investments in family planning programs can contribute to improved maternal and child health, poverty reduction, gender equality, and sustainable development, benefiting individuals, families, and societies as a whole.

Regarding factors influencing family planning usage, most of the respondents (29.2%) strongly disagreed and were of the view that contraceptives are not for married and old people. This is not in line with the qualitative study from Malawi, where a general agreement among respondents was that contraceptives are for married people [26]. The study has also shown that a higher frequency of respondents (27.1%) believed that contraceptives before birth cause infertility, and was in agreement with the qualitative studies from Guinea and Nepal [6, 27]. Moreover, the study found that about 39.1% of the respondents view family planning users as prostitutes. This is in agreement with the studies from Uganda, Kenya, and Nigeria [28–30]. The current study again found that the majority of the respondents (39.1%) indicated that there is a lack of confidentiality and a judgmental attitude of service providers, and this was in line with the study from the United States of America [31].

Moreover, about facilitating factors influencing family planning use, the current study showed that parental involvement in contraceptive decisions is likely to increase FP use (25.5%), and was in line with the study from Nigeria [32]. Also, religious leader acceptance is found likely to increase family planning usage (26.3%) and consistent with the research from Somalia [33]. Furthermore, encouragement from partners/parents is found likely to increase FP use (32.6%), and this was in line with the study from Guinea [34]. Thus, increasing the usage of family planning requires a multi-faceted approach involving parental involvement and support from significant individuals such as religious leaders and partners. By addressing these factors, individuals can make informed choices about family planning, leading to improved reproductive health outcomes.

38

The study revealed a significant association between marital status (p=0.002) and contraceptive usage. This is in agreement with the studies from Zambia and Uganda [35-37]. Also, ever had sex (p < 0.001) was seen to be a factor associated with family planning usage, and was in line with the study from Tanzania []. The study likewise found that the mom’s level of education (p=0.028) and the mother's occupation (p=0.017) were significantly associated with family planning usage. A multivariate logistic regression identified that subjects who had sex were more likely to use family planning compared to those who had never had sex (aOR, 5.93; 95% CI, 2.34-15.03; p<0.001) and this is also in support of the study from Tanzania [38].

Strength and limitation

The strength of this study is that we were able to study a greater number of young people while also employing proper descriptive and inferential statistics. Conversely, the limitation of the study is that the results may have limited applicability for young people, as this study focused solely on individuals aged 15 to 24 years, and also in a single district within the Northern Region of Ghana.

Additional information

No additional information is available for this paper.

Declaration of competing interes

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References