CHAPTER TWO

REVIEW OF RELATED LITERATURE

This chapter reviews the current literature related to knowledge, attitude and practice of long

term family planning among women in Nyanya Community. Finally, this chapter provides a

detailed description of conceptual framework chosen for this study.

2.1 Conceptual Framework for the Study

Bennett’s (1976) knowledge, attitude, skill and aspiration (KASA) Hierarchy model has been

used in evaluating the basic principle for changes. The Bennett’s Hierarchy model was used in

this research.

Fig 1: Bennett’s Hierarchy model

It is one of the first models created to impact change in practice. Bennett proposes that when

participants apply their KASA, this leads to practice change and from practice change comes end

result. This theoretical change model targets outcomes. Before developing an educational
program to improve practice, the researcher must identify what knowledge is needed and assess

the participants’ attitude, skill and desire to change (Bennett, 1976). This framework is about the

intention to act to understand the determinants of modern contraceptive use among women, this

build on exciting knowledge on factor associated with contraceptive used. We hypothesized that

factor associated with contraceptive used operate at different levels. In this study, this conceptual

framework describes how selected socio-demographic such as educational level, occupation and

age will influence practice. For the knowledge, the respondents will answer the questions that

view their knowledge regarding long term family planning either respondent have good

knowledge or poor knowledge. For attitude, to determine the good and poor attitude, it is

influenced by respondent’s knowledge and practice. Therefore, with good knowledge and

attitude, there will be a desire to change the attitude of long term family planning.

2.1.1 Long term family planning

According to the World Health Organization (2018), long term family planning is defined as “the

ability of individuals and women to anticipate and attain their desired number of children and the

spacing and timing of their births. It is achieved through the use of contraceptive methods and

the treatment of involuntary infertility”. The importance of long term family planning is clear

from its benefits to individuals, as well as to families, communities, and societies. Long term

family planning serves three critical need which helps women avoid unintended pregnancies,

reduces the spread of sexually transmitted diseases (STD) and helps reduce rates of infertility.

Long term family planning is adopted voluntarily through the practice of contraception or other

methods of birth control on the basis of knowledge, attitude and responsible decision by

individuals and women, in order to promote the health welfare of the family and contribute to the

social and economic development of the country. Long term family planning has been identified
by the World Health Organization (2018) as one of the six essential health interventions needed

to achieve safe motherhood and by United Nations Children Fund (UNICEF) as one of seven

strategies for child survival. In Malaysia, long term family planning services are provided by

various agencies such as governmental, private and non-governmental organization. The main

provider is Ministry of Health clinic and hospital.

2.1.2 Method in Long term family planning

About 85% of women will become pregnant within one year without contraception (Cleland et

al, 2020). There are number of family planning methods available to women. In this study, these

methods will be classified based on their duration or permanence of effectiveness such as

permanent, temporary/short-term, and Long-term family planning.

The permanent methods include sterilization, bilateral tubal ligation, and vasectomy.

Sterilization involves permanent procedures to prevent pregnancy. Tubal ligation for women

involves blocking or sealing the fallopian tubes, while vasectomy for men involves cutting or

blocking the vas deferens. These methods are considered irreversible and are usually chosen

when a person or women is sure they do not want any more children.

Temporary/short-term methods of family planning includes the use of Birth control pills,

patches, injections, and vaginal rings that contain hormones (usually estrogen and progestin) that

prevent pregnancy by inhibiting ovulation, thickening cervical mucus, or thinning the uterine

lining. While pills, patches, and rings require regular attention (daily, weekly, or monthly),

contraceptive injections can provide protection for several months.

Long term methods of family planning includes intrauterine contraceptive devices (IUCDs)

and Implants. These are current effective methods that prevents unwanted pregnancies. These
methods provide long-term contraception without requiring daily attention. They include

intrauterine devices (IUDs), which are small T-shaped devices inserted into the uterus, and

contraceptive implants, which are small rods inserted under the skin of the upper arm. Both IUDs

and implants can prevent pregnancy for several years, depending on the type. The IUCD is

inserted in to the uterus through the cervix by a trained health professional at any time

convenient to the user, normally within the first seven days after normal menses, or within the

first seven days post abortion, or six to eight weeks post-delivery, or within five days of

unprotected sexual intercourse. O’ Hanley & Huber (2022) also found that insertion of an IUCD

in the post-menstrual and immediate post-partum periods was convenient, efficient, safe and

have a low incidence of infection.

In this study we will focus on IUCDs and Implants as the methods of long term family planning.

2.1.3 Benefits of Long term family planning

Modern contraceptive use has been widely acknowledged to be one of the most cost-effective

strategies for promoting reproductive health and fostering socio-economic development globally

(Smith R., et al 2019) (Adedini S.A et al., 2022). Long term family planning has several

benefits, some of which are specific to the health of mothers and their children. Others include

socioeconomic benefits; for example, women are able to advance their education and careers by

delaying or limiting childbearing and this can bring better economic prospects to their household

(Smith R., et al 2019). Long term family planning serves to reduce child and maternal morbidity

and mortality by preventing unintended pregnancies and unsafe abortions (Scott M. & Sandra T.,

2020). The number of maternal deaths that could be averted during childbirth as a result of a

reduction in the number of pregnancies and induced abortions would be significant (Adogu et al.,
2020). Long term family planning also enables birth spacing, ultimately reducing child mortality

while enhancing the nutritional status of both mother and child (Smith R., et al 2019)

2.1.4 Objectives of Long term family planning

Sexuality education, prevention and management of sexually transmitted infections (STIs),

preconception counselling and management, and infertility management. Long term family

planning’s objective is to encourage individuals and women to take responsible decision about

pregnancy and enable them to achieve their wishes with regard to: preventing unwanted

pregnancy, securing desired pregnancies, spacing of pregnancies, limiting the size of the family

(Lucas & Gilles, 2023). FP is however wider than this, as it may further include: sexuality

education, prevention and management of sexually transmitted infections (STIs), pre-conception

counselling and management, Infertility management (Austin A, 2022).

2.1.5 Women’s Knowledge about Long-term family planning

The use of any long term family planning method depends on the person’s knowledge of the

different long-term family planning available and willingness. In a study among women in

Ghana, only 26% of the participants mentioned long term family planning and health service

providers as a source of their knowledge (Akafuah & Sossou, 2022). Next, other studies in

knowledge and attitude towards long term family planning practice and prevalence of short birth

spacing among residents of suburban area in Terengganu, Malaysia only 31.4% is good

knowledge compared to a study in Kota Bharu which is 57.7% among wives. This could be due

to low education background among the participants and most of them had undergone up to

secondary school only. Therefore, we should provide a better knowledge and information related

to long term family planning so that their practice could be improved and sustained (Nazri &
Shahruddin, 2022). Besides, knowledge of contraceptives among the respondents in women is

generally high with 63.6% of the participants indicating to know at least one method in Northern

Nigeria (Ismaila & Mustapha, 2016). Knowledge of long term family planning is associated with

the place of residence, age and education. This is because, 67% of current user of contraceptive

are between the ages 26-40 years and only 24% are between the ages 41- 59 years. This implies

that contraceptive use is more prevalent among women in the middle age categories while on the

other hand older people are not inclined to use contraceptive due to lack of desire to do so as

some of them may not be sexually active. In education, the highest proportion of the current user

of contraceptive comes from those with high level of education with 56.3%. This shows a

positive relationship between contraceptive use and education. In other word, among those who

currently practice contraception, education is very important factor (Ismaila & Mustapha, 2020).

Moreover, the study in Yemen shows that the respondents among women were further asked

about their knowledge regarding mechanism of long-term family planning and their knowledge

and it was generally poor. Only 176 women (44.0%) knew that contraceptive pills contain

hormones and only 221 women (55.3%) knew that IUCDs are small devices used to prevent

fertilization by a foreign body response in the endometrium, preventing the sperm from reaching

the fallopian tubes but does not affect implantation of the fertilized egg. Husbands were more

knowledgeable regarding condoms, with 356 husbands (89.0%) knowing that the condom acts as

a barrier to prevent sperm from entering the vagina (Almualm, 2021). About 50% of the married

women in Ghanaian mentioned condom as the most common and popular modern long term

family planning device that they were familiar (Akafuah & Sossou, 2022). The least known and

less popular device were spermicidal substance, vasectomy, tubal ligation and norplant. The

majority of the participants 83.9% who had at least secondary school and post- secondary
education, indicated that they had previously used a means of contraception, mostly condoms.

However, 86% of the group indicated they were currently using contraceptive and 64.9% of this

educated group expressed the intention of using contraceptive in the future compared to women

with just primary education and those with no formal education (Akafuah and Sossou, 2023).

The educational background of the married women determines the willingness of women to use a

long term family planning in the future. In India, all of the respondents are aware of the

permanent methods of sterilization. Among the temporary method 86% of the respondents were

aware of condoms, 50% oral contraceptive pill, 32% abstinence and 6% Intra-uterine

contraceptive device (Reddy, Premarajan, Narayan & Mishra 2023). We can see that difference

country have acceptance of the method.

2.1.6 Women’s Attitude towards long-term family planning

Previous research has documented that knowledge is important in changing one’s attitude and

this is evident in many behavioral theories such as the health belief models, trans-theoretical

model stage of changes and the theory for reasoned action. According to the study in Mukalla

Yemen, the attitudinal disposition of the women towards long-term family planning is generally

unfavorable, with 55% of the women having unfavorable and 35.7% having favorable attitude.

This is possible related to cultural and religious beliefs of the people which discourage the

practice unless on medical ground. Essentially, awareness of and towards contraceptive are

affected by socio-economic characteristic (Ismaila & Mustapha, 2020). Next, pertaining to

attitude toward long term family planning 79.1% of women had unsatisfactory attitude towards

long term family planning (Nazri & Shahruddin, 2022). In this study, women in Terengganu

showed that knowledge alone did not influence the attitude. Knowledge was assessed in terms of

awareness toward modern contraception method which was high (Syahnaz et al, 2018) but the
attitude and practice still remain low (Najimudden & Sachchithanantham, 2024). Almost all the

respondents among married women had a favorable attitude towards long term family planning,

which is similar to the study done by Rama Rao et al. who reported that the majority (80%) of

their respondents were in favor of long term family planning. Respondents who had favorable

attitudes to long term family planning cited reasons such as health of the mother or the child,

having fewer children and maintaining one’s standard of living.

2.1.7 Women’s practice of long term family planning

According to the study married women in India and Ethiopia, the ever used contraception

reported by women ranged between 62%-80%. The finding of the study gave us a few possible

indications. The modern contraceptive prevalence rate in our community is still low or there is

probably lack of awareness of modern contraceptive method among women (Syahnaz et al,

2018). Nevertheless, our study had shown a significant improvement in the uptake of

contraception compared to 38% reported from a local study done in 2012 (Nazri & Shahruddin,

2022). Based on this study, majority of the participants has widely adopted condom followed by

oral contraception pill and implanon. A different finding was observed in other countries due to

the variation between culture and availability (Syahnaz et al, 2018). Next, only 65% of the

women in Republic of Iran actually applied a contraceptive. This implies that much still need to

be done to achieve a greater prevalence. This may be due to the fact that the level of education of

the group involved was higher than that of the general population (Pirincci & Oguzoncul, 2008).

In Mukalla Yemen, the study showed the prevalence of long term family planning practice

among women in Mukalla was 39.0%, of which 11.0% are current users and 28.0% are previous

users. There were 61.0% of women who have never practiced long term family planning. The

prevalence of currently practicing modern long term family planning by women in Mukalla (11.0
%) is much lower than that reported for Jordanian women in the 2015 Jordan Husband Fertility

Survey (JHFS) at 26.5% (Warren, Hiyari, Wingo, Aziz & Morris, 2020). However, there was no

study found on long term family planning practices of Yemeni women conducted previously in

order to compare with the results of this study. It is known that many Yemeni women do not

discuss long term family planning with their husbands and are therefore unable to truly know the

status of their husband’s long term family planning practice. It is also conceivable that some

wives may secretly practice long term family planning without the knowledge of their husbands,

especially those wives who perceived their husbands as not supportive of long term family

planning (Almualm, 2020).

2.1.8 Factor Affecting Practice of Long-term family planning

Many factors are known to affect the practice of long term family planning knowledge and

attitudes. The educational level of the women has been reported by many studies to be

proportional to the practice of long term family planning. It has been shown that empowerment

indices for decision- making and freedom of movement for Egyptian women increased steadily

and significantly with education (Kishor et al, 2019). According to Shah, Shah and Radovanovic

(2018), a woman’s education has a stronger negative impact than the man’s on desired and actual

family size in urban areas; while the man’s educational level is more important in rural areas in

Kuwait. In Turkey, it is noted that higher levels of education and wider employment

opportunities for women leads to higher family socio-economic status, which in turn directly

influence the woman’s role in decision- making in family life, leading in turn to more modern

long term family planning practice (Sahin & Sahin, 2023). Therefore, other factors that

influenced the attitude towards long term family planning should be identified and improved.

Those factors include support or barrier from friends, family members, community and health
service beliefs and culture (Nazri & Shahruddin, 2022). In a local study, we found that

prevalence of long term family planning practice was 38.7%. It slightly higher than compare

other study in Nepal 23.0%.

2.2 Theoretical Framework

Understanding the knowledge, attitudes, and practices of long-term long term family planning

among women requires a theoretical framework that accounts for individual cognition, social

influences, and systemic factors. This study presents a theoretical framework drawing on several

key theories to elucidate the complex interplay of factors shaping women's engagement with

long-term family planning.

2.2.1 Health Belief Model (HBM)

The Health Belief Model posits that health-related behaviors are influenced by perceptions of

susceptibility, severity, benefits, and barriers. Applied to long term family planning, women's

decisions to adopt long-term are influenced by their perceptions of the risks of unintended

pregnancy, the severity of potential consequences, and the perceived benefits and barriers

associated with different contraceptive options.

2.2.2 Theory of Planned Behavior (TPB)

The Theory of Planned Behavior emphasizes the role of attitudes, subjective norms, and

perceived behavioral control in predicting intentions and behaviors. Women's attitudes toward

long-term long term family planning, influenced by cultural, social, and individual factors, shape

their intentions to use these methods. Subjective norms, including societal and familial

expectations, influence women's perceptions of the acceptability of long term family planning,
while perceived behavioral control reflects women's confidence in their ability to access and use

long-term methods effectively.

2.2.3 Social Cognitive Theory (SCT)

Social Cognitive Theory highlights the dynamic interplay between individual cognition,

behavior, and the social environment. Women's knowledge of long-term long term family

planning is acquired through social learning processes, including observation, modeling, and

reinforcement. Attitudes toward long term family planning are shaped not only by individual

beliefs but also by social influences, such as partner and family support or societal stigma.

Additionally, self-efficacy beliefs play a crucial role in women's adoption and maintenance of

long term family planning practices, influencing their confidence in their ability to navigate

barriers and overcome challenges associated with long-term method use.

2.2.4 Ecological Systems Theory (EST)

Ecological Systems Theory emphasizes the interconnectedness of individuals with their social,

cultural, and physical environments. Women's engagement with long-term long term family

planning is situated within multiple levels of influence, including interpersonal relationships,

community norms, healthcare systems, and broader socio-political contexts. Factors operating at

each level, such as partner communication, community attitudes toward contraception,

healthcare access, and policy support for long term family planning, shape women's knowledge,

attitudes, and practices regarding long-term methods.

A theoretical framework that integrates the Health Belief Model, Theory of Planned Behavior,

Social Cognitive Theory, and Ecological Systems Theory provides a comprehensive lens for
understanding the knowledge, attitudes, and practices of long-term long term family planning

among women. By considering individual cognition, social influences, and systemic factors, one

can develop targeted interventions to promote informed decision-making, enhance access to

high-quality long term family planning services, and ultimately improve reproductive health

outcomes for women worldwide.

2.3 Empirical studies using relevant sub-headings

This review synthesizes findings from various empirical studies on the knowledge, attitude, and

practice (KAP) of long-term family planning among women. It examines the purpose of these

studies, the sample and sampling techniques used, the instruments of data collection, and the

methods of data analysis employed.

2.3.1 Purpose of the Studies

In a cross-sectional study carried out by Nansseu et al. (2015) on contraceptive prevalence,

knowledge, attitude and practice among women in the city of Yaoundé, Cameroon, the primary

objective was to evaluate women's knowledge about long-term family planning, their attitudes

towards using these services, and their actual practices. The study aimed at identifying the

factors influencing family planning decisions and to provide insights that can improve the design

and delivery of family planning programs. Nansseu et al. (2015) aimed to understand the

determinants of contraceptive use to inform policy and enhance family planning services.

Similarly, Alemayehu et al. (2016) on his work on factors associated with utilization of long-

acting and permanent contraceptive methods among married women of reproductive age in

Mekelle town, Tigray region, North Ethiopia focused on identifying barriers to the adoption of

long-term methods in order to recommend targeted interventions.

2.3.2 Sample and Sampling Techniques

These studies done by Nansseu et al. (2015) and Alemayehu et al. (2016) typically employed

various sampling techniques to ensure a representative sample of women of reproductive age

(15-49 years). These methods include:

Purposive Sampling: Samples were selected based on specific characteristics, such as being of

reproductive age and living in a particular community. This method ensured that the sample

included women who are most relevant to the study objectives (Adewale & Afolabi, 2021).

Systematic Random Sampling: This involves selecting participants at regular intervals from a

larger population list, which helped in obtaining a more representative sample (Nansseu et al.,

2015).

Cluster Sampling: Used to ensure geographic diversity by dividing the area into clusters and

randomly selecting participants from each cluster. This technique is beneficial in community-

based studies where geographic representation is crucial (Alemayehu et al., 2016).

The sample sizes varied but generally ranged from 200 to 500 participants, providing sufficient

data for robust statistical analysis.

2.3.3 Instruments of Data Collection

The primary instrument for data collection in these studies was the structured questionnaire.

These questionnaires were pretested and validated to ensure reliability and accuracy. They

typically include sections on:

Demographics: Age, education, marital status, and number of children.

Knowledge: Awareness of different family planning methods, sources of information, and

understanding of the benefits and side effects.

Attitudes: Personal and societal attitudes towards family planning, cultural and religious beliefs,

and perceived barriers.

Practices: Current and past use of family planning methods, reasons for choosing specific

methods, and adherence to long-term methods.

Alemayehu et al. (2016) used a detailed questionnaire with both closed and open-ended

questions to capture quantitative and qualitative data. Additionally, focus group discussions

(FGDs) and in-depth interviews (IDIs) were often used to complement questionnaire data and

provide deeper insights into personal and societal factors affecting family planning decisions

(Eze et al., 2019).

2.3.4 Methods of Data Analysis

Quantitative data from questionnaires were analyzed using statistical software like SPSS. The

analysis typically involves:

Descriptive Statistics: Frequencies, means, and percentages to summarize the data.

Inferential Statistics: Chi-square tests, logistic regression, and other multivariate analyses to

identify significant predictors of family planning practices (Nansseu et al., 2015).

Qualitative data from FGDs and IDIs were analyzed using thematic analysis. This method

involved coding the data into themes and sub-themes to identify patterns and deeper meanings
related to KAP of family planning. For instance, Eze et al. (2019) used thematic analysis to

explore cultural and religious influences on family planning decisions.

2.3.5 Key Findings

These studies consistently showed varying levels of knowledge about long-term family planning

methods. While many women were aware of at least one method, there are significant gaps in

comprehensive knowledge. Attitudes towards family planning are generally positive, but cultural

and religious beliefs often pose barriers. The actual practice of long-term methods is less

common due to misconceptions, fear of side effects, and limited access to services (Alemayehu

et al., 2016; Nansseu et al., 2015).

The reviewed studies provide valuable insights into the KAP of long-term family planning

among women. They highlight the importance of enhancing educational and counseling services

to address knowledge gaps and misconceptions. Tailoring family planning programs to the

specific needs and contexts of women can improve uptake and promote better reproductive

health outcomes.

2.4 Appraisal of Reviewed Literature

2.4.1 Purpose of the Studies

Examining the above literature on the knowledge, attitude, and practice of long-term family

planning among women reveals a nuanced understanding of factors influencing contraceptive

decision-making. The purposes of these studies by Alemayehu et al., (2016) and Nansseu et al.,

(2015) were well-conceived and crucial for public health, particularly in the context of

developing regions where family planning is essential for improving maternal and child health
outcomes. By focusing on the knowledge, attitudes, and practices (KAP) related to long-term

family planning among women, these studies address significant gaps in understanding that can

influence policy and programmatic interventions. However, while the objectives are relevant and

timely, there is a noticeable need for more longitudinal and intervention-based research to

understand how knowledge and attitudes evolve over time and how different interventions might

improve long-term family planning practices. This is one of the things this study aims at

achieving.

2.4.2 Sample and Sampling Techniques

The sampling techniques used by Alemayehu et al., (2016) and Nansseu et al., (2015) in their

studies, such as purposive and systematic random sampling, are generally appropriate for

capturing a representative sample of the target population. These methods ensure that the studies

cover a diverse group of women, which is crucial for generalizing the findings. However, the

sample sizes, while adequate, could be expanded to enhance the statistical power of the studies.

Moreover, incorporating random sampling more consistently across studies would further

strengthen the reliability of the results. This also is what I intend to achieve in this study.

2.4.3 Instruments of Data Collection

The structured questionnaires used in these studies by Alemayehu et al., (2016) and Nansseu et

al., (2015) were effective tools for gathering comprehensive data on KAP. Their use of both

closed and open-ended questions allowed for a detailed analysis of quantitative and qualitative

data. Pretesting these instruments to ensure reliability and validity was a strength, as it enhanced

the credibility of the findings. Nonetheless, expanding the use of mixed methods—integrating

more qualitative tools like in-depth interviews and focus group discussions—could provide
deeper insights into the contextual and subjective factors influencing family planning practices.

This study will look to explore the use of in-depth interviews.

2.4.4 Methods of Data Analysis

The studies employed appropriate methods for data analysis, utilizing statistical software like

SPSS for quantitative data and thematic analysis for qualitative data. The use of descriptive and

inferential statistics helped identified key trends and significant predictors of family planning

practices. However, there is room for more advanced statistical techniques, such as multivariate

analysis, to uncover more complex relationships between variables. Additionally, triangulating

data from multiple sources and methods could enhance the validity and reliability of the findings.

More sophisticated analytical approaches could provide deeper insights into the data and help

identify more nuanced factors influencing family planning decisions.

2.4.5 Key Findings

The key findings of these studies provided valuable insights into the knowledge, attitudes, and

practices of long-term family planning among women. They highlighted significant knowledge

gaps and barriers to the practice of long-term family planning, such as misconceptions, fear of

side effects, and limited access to services. While these findings are insightful and critical for

informing policy and programmatic interventions, the studies often lack actionable

recommendations. There is a need for more detailed exploration of how specific cultural and

religious beliefs impact family planning decisions and how these barriers can be effectively

addressed. Including perspectives from other stakeholders, such as healthcare providers and male

partners, could provide a more holistic understanding of the factors influencing family planning

practices.
Overall, the studies on the KAP of long-term family planning among women provided valuable

insights and contributes significantly to the field of reproductive health. They highlighted

important gaps in knowledge and barriers to the use of family planning methods, underscoring

the need for enhanced educational and counseling services. However, there are opportunities to

improve future research. Longitudinal and intervention-based studies, larger sample sizes, more

diverse data collection methods, and advanced analytical techniques could provide more

comprehensive and actionable findings. By addressing these areas, future research can offer

more robust recommendations that can significantly impact policy and practice in reproductive

health