Awareness and practices of contraceptive use among university students in Botswana

In Botswana, unplanned pregnancies, especially among the youth constitutes a growing health and social problem. Research in the field of contraceptive practices, and the causes of sexual practices in Botswana, remains scarce and relatively limited. The objectives of this study was to investigate the awareness and utilization of various contraceptive methods, among university students in Botswana. A descriptive, cross-sectional, research study was conducted among 346 randomly selected students, who completed confidential, self-administered questionnaires. The average age of the respondents was 21 years (SD = 2.8 years). The level of awareness among students regarding contraception was good (score ≥9). Both the male and the female students had almost similar awareness level of contraceptive use, as their mean scores were 8.79 and 8.72, respectively (p = .733). All the female students (100%) were ‘aware’ that the effectiveness of the contraceptives used, as compared to male students, being 93.7%. A greater proportion of the female students (90.6%) knew that using contraceptives irregularly would result in pregnancy, in contrast to 76.4% males. More than half (59.0%) of the students indicated that they had engaged in sexual acts. Significantly, more male students (68.5%) had sexual experiences prior to the study, compared to 54.5% of their female counterparts (p = .038). The majority of the students (76%) reported that they had always used contraceptive methods. The most commonly used contraceptive method was the condom (95.6%), followed by oral contraceptive pill (86.7%). There was no significant association found between the level of awareness and the use of contraceptives. Results suggested that many students still engaged in risky, contraceptive practices by engaging in unprotected sexual acts. Therefore, there is a need to educate the students about sexually transmitted infections, the different contraceptive methods and the regular use of the available contraceptives.


Introduction
An unplanned or an unwanted pregnancy is a serious, global public health problem (Kang & Moneyham 2008). It is estimated that about 80 million, unplanned pregnancies occurs in the world every year (Speidel, Harper & Shields 2008). Unplanned pregnancies may be prevented by using the contraceptive methods, such as the oral contraceptive pills, the long-term hormonal injections, the condoms, the tubal ligation or a vasectomy (Contraceptive Chart 2008). There are also emergency contraceptives available to prevent unplanned pregnancies, and should be obtained and taken within 72 hours after engaging in unprotected sexual intercourse (Steyn & Mason 2009).
Contraceptives are available with no charge from the government health facilities in Botswana. These facilities include referral hospitals, primary hospitals, main clinics, university clinics, mobile clinics, health posts and the Botswana Family Welfare Association, and sexual and reproductive centres. These health centres are located within a 15-kilometre radius from the residents homes (UNFPA Case Study 2003).In Botswana, a study done on the youth on reproductive and sexual health issues, revealed that over a quarter of the women aged 15 -19 years were pregnant (Advocates for Youth 2009). The overall prevalence rate of contraceptive use among married women was 44% (Population Reference Bureau 2012). Another study found that one in every three women who were single or teenagers and between the ages of 15 and 49 years was pregnant because of unprotected sex (Mookodi, Ntshebe & Taylor 2004).
In Botswana, about 90% of the university student's fees are sponsored by the government. These university students are classified within the university community as 'unplanned pregnancy groups', and viewed as being 'not yet ready to be parents'. The unplanned pregnancies may occur as a result of not utilizing contraceptive methods or due to the failure of the chosen contraceptive methods used. Therefore, the unplanned pregnancies that occurs each year has a negative impact on Botswana's economy. It impacts on the tax payers while the students may extend and interrupt their studies. While contraceptives methods are offered free of charge in government health facilities, the information on contraceptive use in general, is not easily available in Botswana to the young students (Advocates for Youth 2009). Therefore, the objectives of this study were to investigate the awareness and practices of contraception among the University students in Botswana.

Methodology Study design and setting
This study used a descriptive, cross-sectional study design. The setting was the main campus at the University of Botswana in Gaborone, Botswana. This University was established in 1982 and has four campuses, two in Gaborone, one in Francistown and one in Maun. The seven specialities offered within the faculties are Business, Education, Engineering, Humanities, Science, Social Sciences and the School of Medicine.

Study population
The study population consisted of all the registered, undergraduate students ranging from the first to the fifth years at the University of Botswana, main campus in Gaborone. Currently there are 14,093 students, 11,587 are full-time, 2614 part-time and 505 distance learning students. The total enrolment in the faculties are 26% in business, 12% education, 6% engineering, 3% medicine, 17% humanities, 9% science and 16% social sciences. Approximately 45% of the students' were males and 55% were females.

Sample size
A minimum sample size was used for the study, and was calculated, using a standard formula as described by Reid and Boore (1991). The total population of students at the university was 14,093. A sample size of 389 was obtained. Ten per cent more of the sample was added to the total to cover the number of dropouts of the students. Therefore the calculated sample size was 428.

Inclusion and exclusion criterion
The respondents were all the registered, full-time undergraduate students from all years of study at the main campus of the University of Botswana. Both males and females, pregnant or non-pregnant that were willing to participate in the study were included in the study. All part-time undergraduates and postgraduates (part time or full time) students from the main campus of the University of Botswana were excluded from the study.

Ethical considerations
Ethical approval for the study was obtained from the University of Limpopo, Medunsa Research and Ethics Committee, South Africa, the Human Research Development Committee of the Ministry of Health Botswana, and the Director of Student Affairs, University of Botswana, Gaborone Botswana. The informed consent form was signed and obtained from the respondents. Confidentiality of the respondents was maintained at all times. Anonymity was maintained by not disclosing the identity of the respondents. Participation was voluntary and the respondents were informed that they could withdraw from the study at any stage, if they so desired without any penalty.
The second section consisted of 'awareness' regarding questions on contraception. This section had 14 questions of which 13 questions had yes, no and do not know answers and only one was correct. The last question consisted of multiple answers requesting the respondents to indicate the methods of contraception. The last section dealt with respondent's utilization of contraceptives.

Data collection
Simple random sampling method was used to select samples for the study. The students were recruited from strategic points and areas used by the students within the university community. The strategic points selected were the University Library entrance, the Dining Area (Refectory), the Tuck-shop and the student's community centre. A self-administered questionnaire was used to collect the data and was distributed from the main campus. The questionnaires were in English as this is the medium used to teach at the University of Botswana.
Pre-testing of the questionnaire was conducted using 20 students from the college of health sciences to identify gaps and modify the questionnaire. The students who participated in the pre-test were not part of the main study.

Data analysis
Data were entered into a Microsoft Excel 2003 spreadsheet and analysed, using the SPSS 18.0.1. The demographics and outcome variables were summarized using descriptive summary measures, expressed as means (SD) for continuous variables and percentage for categorical variables. Chi-square test was used to determine the test of association between the categorical variables. All the statistical tests were performed using twosided tests at the .05 level of significance. P-values reported to three decimal places with values less than .001 reported as ,.001. P-values less than .05 were considered statistically significant.

Results
A total of 346 students completed the questionnaires, with a response rate of 80.8%. Table 1 shows the demographic information of the respondents. The mean age of the students was 20.51 years (SD ¼ 2.85 years).The majority of the students (75.5%) were between the ages 19 -23 years and 68% were females. More than a third of the students were from first year (38.4%) and second years (35.5%), respectively. The majority of the respondents (82.4%) stayed off-campus, and among them 76.5% stayed with their parents and 16.1% staying alone.

Awareness regarding contraceptives
Overall, the male and female students had 'good awareness regarding contraceptives' as more than half of them (58.6% and 59.1%) for both males and females respectively scored nine or above. The males and the females also had almost 'similar awareness' as their mean scores were 8.79 and 8.72, respectively (p ¼ .733). The respondents' responses regarding contraception are summarized in Table 2. All the female students (100%) were 'aware' that contraceptives are not 100% effective as compared to 93.7% of the male students. More females (90.6%) compared to males (76.4%) knew that using contraceptives irregularly will result in pregnancy. In terms of the other variables, there was no variation noted between the 'awareness' of females as compared to the awareness of male. The most commonly known contraceptive method used was the condom (95.6%) followed by 86.7% of the oral contraceptive pill. Table 3 shows the respondents contraceptive practices. More than half (59.0%) of the students indicated that they had engaged in sexual intercourse. More male students (68.5%) had sex before the study as compared to their female counterparts (54.5%), and the rates were significantly different (p ¼ .038).
The main source of information received regarding contraceptives use was the school or the health facility (78.3%) followed by television and radio (Table 4). Students reported that their preferred places of accessing contraceptives were the clinics followed by the university clinics. No significant association was found between the 'awareness level' and the use of contraceptives (p ¼ .085).

Discussion
This study aimed to investigate university students awareness and practices regarding contraceptive use in Botswana. Overall, the students had an above average awareness level and the majority used some form of contraceptive. No association was found between the awareness level and contraceptive practices.
The mean age of the students was 21 years (+2.85) and most of the students were between the ages of 19 and 23 years. In Botswana, 80% of the children start school at around seven to eight years of age; therefore most students were within this age group, as they were now 19 years and since completion of secondary school. More than 60% were females and this was quite similar

Awareness regarding contraceptives
The respondents in this study generally had good awareness regarding contraceptives. All the female students knew that contraception was not 100% effective. Irregular uses mean using contraceptives sometimes, for example using condom sometimes, skipping the pill or delayed taking of the injectable after the scheduled type. The findings of this study are contrary to the findings of a study in South Africa, as it was found that awareness regarding irregular use was 21% among female respondents as compared to 90.6% among female respondents in this study (Oni, Prinsloo, Nortje & Joubert 2005). The condom (95.6%) was the most commonly known method followed by the oral contraceptive pill (86.7%). This finding contradicted earlier findings of Mookodi et al. (2004), where the condom was reported to be known to all the participants. In a South African study, awareness of contraception on condom use among the males and females was 72.9% and 74.2% (Oni et al. 2005). Norplant was the least  Wait for a month to see if pregnant 10.9 11.9 Seek emergency pill 33.8 33.9 Do not know 19.7 13.1 a Use of more than one method of contraceptive. b Males n ¼ 76, females n ¼ 128.

Original Article
Journal of Social Aspects of HIV/AIDS VOL. 10 NO. 2 JUNE 2013 known method (24.6%). But this finding is much higher than the Nigerian study, where only 5.7% students were aware of Norplant (Oyedokun 2007).
About two-thirds of the respondents mentioned that they had engaged in sexual intercourse. This is similar to the South African study which reported that 65.7% of the university students had had sex prior to the study (Hoque & Ghuman 2011).
The majority of the sexually active respondents indicated that they were using contraceptives, even though a quarter were not using them regularly. Studies from Ethiopia and Nigeria concluded that only 10% and 30.1% used contraceptives regularly (Oyedokun 2007;Tamire & Enqueselassie 2007). A recent South African study reported that 67.8% of the sexually active students were using contraceptives, sometimes or rarely (Hoque & Ghuman 2011).
The findings of this study showed that the condom is the most commonly used method, among both males and females, followed by the withdrawal method. The finding of this study is similar with that of the Central Statistics Office (2006) which reported that 93.3% of the sexually participants used condoms. The study in Ethiopia reported that the contraceptive method mostly used was the pill, followed by the injection (Tamire & Enqueselassie 2007). Botswana is one of the countries most severely affected by HIV/AIDS. Condoms were highly marketed and available almost everywhere in the country.
The present study found that both males and females (61.1%) preferred to access contraceptives from clinics, but not the university clinic. The university clinic was the next preferred followed by pharmacies. In Botswana as contraceptives could be accessed free of charge in government facilities, it is not surprising to see the clinics being the main access points, but the same was expected for hospitals and youth facilities as well. One may argue that the clinics are many and easily accessible, as compared to the hospitals; however, the youth facilities are also many but different trends on preferences was found. The reason may be due to the lack of information about the youth facilities, unfriendly attitudes of service providers to youth or inconvenient hours as was mentioned in a case study by UNFPA Case Study (2003).
The findings of this study indicated that the most common source of information obtained regarding contraception, was mostly from schools and health facilities. This is contrary to a previous study from Botswana which found that the most common source was friends and HIV programmes (Francoeur & Noonan 2004). This is also in contrast to a study done in Nigeria whereby 51.2% indicated hospital or clinics (Oyedokun 2007 No association was found between the level of awareness and contraceptive use. The awareness level was 'good but' there is still a need to investigate, if this 'awareness results' can be acceptable for use, since literature generally agrees that better 'awareness' about contraception, increases the chances of better contraceptive practices (Oyedokun 2007).

Limitations of study
There were numerous limitations that could arise from the study methodology. The study population consisted of students at one university, and it might not be advisable to generalize our results with regard to other universities. Students' behaviours were self-reported. Although the surveys were anonymous, there might be information bias because some students may have been reluctant to report sensitive information regarding contraceptive practices. To minimize this type of bias, confidentiality was ensured.

Conclusion
The study found that the level of 'awareness' was 'good' between both males and females and was 'satisfactory' to sustain adequate contraceptive use, in the context of the 'high' unplanned pregnancy rate. The condom was the most popular method used by most respondents, showing that the HIV/ AIDS prevention strategy in Botswana is working well, in attracting condom use by this student population. Sexual practices of some of the respondents remain at risk, as there are still many students engaging in unprotected sexual acts. Contraceptive use has to be 'high', even though there were instances of infrequent use, with the most commonly used method .being the condom. The university management should organize workshops on regular basis at the university on changing reproductive health and sexual behaviour, as well as health education programmes.