Objective: To assess the factors contributing to the intention to use long-acting reversible contraception among women of reproductive age during the coronavirus disease-2019 pandemic.
Method: The cross-sectional study was conducted in Mlajah village, Bangkalan Madura, Indonesia, from May 25 to June 30, 2021, and comprised married women of reproductive age. Attitude, subjective norm, perceived behavioural control and intention to use long-acting reversible contraception were the elements explored using a questionnaire based on the Theory of Planned Behaviour. Data was analysed using Spearman’s Rho.
Results: Of the 102 subjects, 46(45.1%) were aged 30-39 years, 51(50%) had college or university education, 43(42.2%) had 2 children and 59(57.8%) were using family planning methods. There was a significant relationship of intention to use long-acting reversible contraception with attitude (p=0.000; r=0.566), subjective norm (p=0.000; r=0.475), and perceived behavioural control (p=0.000; r= 0.691).
Conclusion: The intention to use long-acting reversible contraception among married women of reproductive age was significantly associated with attitude, subjective norm and perceived behavioural control.
Keywords: Behaviour control, Optimism, Contraception, Family planning, COVID-19, Women’s health. (JPMA 73: S-84 [Suppl. 2]; 2023)
Social distancing are policies made to reduce the transmission process of coronovirus disease-2019 (COVID-19).1 This condition causes a tremendous impact, one of which is on public health services, including family planning (FP) services.2 Reduced access to FP services can cause dropout (DO) from FP participation, which causes various problems, like an increase in the number of unwanted pregnancies.3
According to the National Family Planning Coordinating Agency (NFPCA), in July 2020, the DO rate was 10.46%. This number increased 9.33% from February 2020.4 The NFPCA chapter in East Java province stated an increase in the number of pregnancies by 8.58% from 2019 to 2020. The number of couples of childbearing age in East Java was 7,849,073, and those who were pregnant until April 2020 were 227,260, or around 2.9%. If the next month followed the pattern, it was estimated that by the end of 2020 there would be as many as 681,780 pregnancies.5 The DO rate in Bangkalan Regency during the pandemic was relatively high at 13.26% and was above the provincial average. The Bangkalan office of women’s empowerment, child protection and family planning service stated that, during the pandemic in March-April 2020, there was an increase of 200 pregnant women.6
The FP programme is used to control the rate of population growth. long-acting reversible contraception (LARC) include intrauterine devices (IUDs), implants and regular contraception.7 LARC has a high level of effectiveness with a low failure rate and fewer complications and side effects than other contraceptive methods in preventing pregnancy.8 LARC is also relatively safer and more efficient because it only requires one installation for an extended period.9 LARC was recommended during the pandemic, but since the installation of LARC required visiting some health facility, the use got reduced in the active phase of COVID-19.10
Permanently delaying pregnancy during the pandemic was promoted and people were encouraged to actively participate in FP programmes.11 The FP use is based on an intention beforehand. Strong intentions increase the chances of women of childbearing age (WUS) using LARC.12 According to the Theory of Planned Behaviour (TPB), behaviour is a conscious effort mediated by intention, and intentions are influenced by three main predictors: attitudes, subjective norms and perceptions of behavioural control.13
The current study was planned to analyse factors influencing the intention to use LARC in women of childbearing age during the pandemic.
Subjects and Methods
The descriptive, correlational, cross-sectional study was conducted in Mlajah village, Bangkalan Madura, Indonesia, from May 25 to June 30, 2021, after approval from the institutional ethics review committee. The sample size was calculated using the Lemeshow formula.14 The sample was rasied using purposive sampling technique. Those included were married women of reproductive age in the 19-49 years bracket who could communicate well both orally and in writing. Women who had not had children, had a hysterectomy or had menopause were excluded. In line with TPB,15 the attitudes, subjective norms and perceptions of behavioural control were taken as independent variables, and the intention to use LARC as the dependent variable.
Data was collected using a questionnaire based on TPB.13 The questionnaire was found valid and reliable after tests were carried out on 15 women of childbearing age who had the same characteristics as the study respondents.
It was scored using a 4-point Likert scale; = Strongly Agree, 3 = Agree, 2 = Disagree, 1 = Strongly Disagree. The negative statements were scored in the reverse format. Attitude variable assessment scored code 2 if T value was median, and negative code 1 if T value less than median. The overall scores were categorised as Good 76-100%, Sufficient 60-75%, and Less <60%.
Data collection was carried out after obtaining informed consent. Questionnaires were given directly to respondents by complying with health protocols. Data was analysed using Descriptive statistics. Inferential analysis was done using Spearman Rho. P<0.05 was considered significant.
Of the 102 subjects, 46(45.1%) were aged 30-39 years, 51(50%) had college or university education, 43(42.2%) had 2 children and 59(57.8%) were using FP methods (Table 1).
Previous information about LARC has been received mostly through health workers 72(70.6%) (Table 2).
There was a significant relationship of intention to use long-acting reversible contraception with attitude (p=0.000; r=0.566), subjective norm (p=0.000; r=0.475), and perceived behavioural control (p=0.000; r= 0.691) (Table 3).
The Madurese community is a religious society with a strong culture and tradition. Most of the respondents in the current study stated that their religion/belief did not prohibit the use of LARC. The approach to the community through community-based religious leaders, for FP promotion, supports government programmes in this regard.
Most of the respondents had a negative attitude, but with sufficient intention to use LARC during the pandemic. The negative attitude was triggered by a lack of belief in the benefits of LARC. Negative attitudes toward contraception can be caused by limited knowledge about contraception.16 Sources of information also affect a person’s understanding. Women who know LARC better understand the benefits and side effects of LARC, and have a higher chance of taking advantage of it.17
The majority of respondents had subjective norms sufficient and sufficient intention. According to TPB, two factors can influence a person’s subjective norms to generate behavioural intentions; individual perceptions of the expectations of other people who influence their lives, and motivation to fulfil or not meet the norms of others.18 Expectations of spouse (husband/wife), friends, family, co-workers, or doctors can influence a person while considering a behaviour.13
Decision-making about using LARC supported by husbands has a two times greater chance of making decisions made by women alone. The couples of childbearing age practise FP because of their health, not religion. Religion does not forbid a person from having many offspring, but stresses on the quality of children.19 Women of childbearing age who have good health support have a greater chance of choosing LARC. Health workers are expected to have good communication skills to motivate the community to use appropriate FP method by providing counselling and assisting families.20
Most respondents perceived sufficient behavioural control and had sufficient intention in the current study. The encouragement to use LARC is because they had high confidence in the resources and opportunities. Perception of behavioural control is determined by the driving factors that support or inhibit the behaviour from being carried out and the strength of the driving influence in realising the behaviour. Someone who has strong ‘control beliefs’ will affect how they perceive the ease or difficulty of performing the behaviour.13 Factors that influence the use of LARC include age, education level, occupation, sources of FP services, and area of residence.21
Knowledge increases a person’s awareness of the importance of something that causes someone to want to do something.22 Ease of access and distance to health services also encourage women to use LARC. Access support, such as distance, travel time, availability of transportation, and road conditions, affect the affordability of acceptors in approaching FP services.23 Another factor affecting the use of LARC is the cost factor, which influences the control of a person’s behaviour at large.24 The respondents in the current study said there was no problem if they had to pay for using LARC. The cost of using LARC is considered cheaper in terms of effectiveness and duration of use than non-LARC contraception.25 Individuals with a high perception of behavioural control will continue to be motivated because of their confidence in the resources and opportunities.26
The current study has limitations, like using a cross-sectional design that only emphasizes the measurement of variables at one particular time. Besides, information provided through closed-ended questions may carry biases. Also, The behavioural measurement needed to be done by exploring the respondents’ experience in detail.
The intention to use long-acting reversible contraception among married women of reproductive age was significantly associated with attitude, subjective norm and perceived behavioural control.
Acknowledgement: We are grateful to the cadre in charge of Mlajah village primary healthcare, Bangkalan Madura, to the study subjects, and to the Faculty of Nursing, Universitas Airlangga, Indonesia. Special thanks are due to Dr Amel Dawod Kamel Gouda, from Kingdom of Saudi Arabia, for critical intellectual content suggestions.
Disclaimer: The text was presented as an oral presentation at the 13th International Conference held by the Faculty of Nursing, Universitas Airlangga, Indonesia.
Conflict of Interest: None.
Source of Funding: None.
1. Hamilton K, Smith SR, Keech JJ, Moyers SA, Hagger MS. Application of the Health Action Process Approach to Social Distancing Behavior During COVID-19. Appl Psychol Health Well Being 2020;12:1244-69. doi: 10.1111/aphw.12231.
2. Wood SN, Karp C, OlaOlorun F, Pierre AZ, Guiella G, Gichangi P, et al. Need for and use of contraception by women before and during COVID-19 in four sub-Saharan African geographies: results from population-based national or regional cohort surveys. Lancet Glob Health 2021;9:e793-801. doi: 10.1016/S2214-109X(21)00105-4.
3. Weinberger M, Hayes B, White J, Skibiak J. Doing Things Differently: What It Would Take to Ensure Continued Access to Contraception During COVID-19. Glob Health Sci Pract 2020;8:169-75. doi: 10.9745/ GHSP-D-20-00171.
4. National Population and Family Planning Agency (BKKBN). Performance Report: Government Agencies. Jakarta, Indonesia: National Population and Family Planning Agency (BKKBN); 2021.
5. National Family Planning Coordinating Board. Talkshow with RRI Surabaya Station “Baby Boom Threats After the Covid-19 Pandemic”. [Online] 2020 [Cited 2020 December 14]. Available from URL: http://jatim.bkkbn.go.id/talkshow-bersama-stasiun-rri-surabya-ancaman-baby-boom-pasca-pandemi-covid-19/
6. Central Bureau of Statistics of Bangkalan Regency (BPS). People’s Welfare Statistics in Bangkalan Regency. Jakarta, Indonesia: Central Bureau of Statistics (BPS); 2021.
7. Choiriyah L, Armini NKA, Hadisuyatmana S. Males’ Supports and Perspectives on Using and Selecting Long-Term Contraceptive Aids: A Descriptive Inquiries. Indones J Community Heal Nurs 2020;5:72-9. Doi: 10.20473/ijchn.v5i2.18481
8. Huda, N, Baroya NI mal, Sandra, C, Hariastuti I. Family Planning Village Program In Response To The Use Of Long-Term Contraceptive Method. Indonesian Journal of Health Administration 2020;8:78–89. Doi: 10.20473/jaki.v8i1.2020.78-89
9. Indarti J, Christiawan L, Suhartomo D, Caroline C, Loho D. Postpartum contraceptive use among pregnant women who delivered at Cipto Mangunkusumo General Hospital: A descriptive study. Maj Obs Gin 2021;29:124-8. Doi: 10.20473/mog.V29I32021.124-128
10. Aly J, Haeger KO, Christy AY, Johnson AM. Contraception access during the COVID-19 pandemic. Contracept Reprod Med 2020;5:1-9. Doi: 10.1186/s40834-020-00114-9
11. Indonesian Obstetric and Gynecological Association (POGI). Recommendations for Handling Corona Virus Infection (Covid-19) in Maternal (Pregnant, Maternity and Postpartum). Surabaya, Indonesia: Indonesian Obstetric and Gynecological Association (POGI); 2020.
12. Joeliatin, Murti B, Suryani N. Theory of Planned Behavior on the Determinants of Participationin the Long-Term Contraceptive MethodAmong Women of Reproductive Age, in Nganjuk, East Java. J Health Promotion Behavior 2016;1:171-9. Doi: 10.26911/thejhpb. 2016.01.03.04
13. Ajzen I. The theory of planned behavior: Frequently asked questions. Hum Behav Emerg Technol 2020;2:314–24. Doi: 10.1002/hbe2.195
14. Lwanga SK, Lemeshow S. Sample size determination in health studies: a practical manual. Geneva, Switzerland: WHO Press; 1991.
15. De Leeuw A, Valois P, Ajzen I, Schmidt P. Using the theory of planned behavior to identify key beliefs underlying pro-environmental behavior in high-school students: Implications for educational interventions. J Environ Psychol 2015;42:128-38. Doi: 10.1016/j.jenvp. 2015.03.005
16. Dewati M, Kusumaningrum T, Pradanie R. Determinant ofBehavior of Contraception Selection in Early Marriage Young Mother. Pediomaternal Nurs. J 2020;6:41-8. Doi: 10.20473/pmnj.v6i1.15857
17. Biza N, Abdu M, Surender R. Long Acting Reversible Contraceptive Use And Associated Factors Among Contraceptive Users In Amhara Region, Ethiopia, 2016. A Community Based Cross Sectional Study. Medico Research Chronicles 2017;4:469–80.
18. Sari AP, Armini NKA, Kusumaningrum T. Factor association related to husband’s support behaviour in the cervical cancer prevention based on theory of planned behavior. Int J Psychosoc Rehabilitation 2020;24:3979-90. DOI:10.37200/IJPR/V24I2/PR200716.
19. Azis R, Mahmud A, Arsyad SS. Options Of Long-Term Contraceptive Methods In Married Women In South Sulawesi (Analysis Of Idhs 2017). Jurnal Biometrika dan Kependudukan 2021;10:191-201. DOI: 10.20473/jbk.v10i2.2021.191–201.
20. Nastiti AA, Pradanie R, Sari DR. Choosing intrauterine device of mothers in rural area, Indonesia: Based on Health Belief Model Theory. Enferm Clin 2021;31(Supp 2):S343-7. Doi: 10.1016/j.enfcli. 2020.12.038.
21. Triyanto L, Indriani D. Factors Affecting The Use Of Method Types Long-Term Contraception (Mkjp) In Married Women Subur In East Java Province. The Indonesian Journal of Public Health 2018;13:244- 55.
22. Arlinghaus KR, Johnston CA. Advocating for Behavior Change With Education. Am J Lifestyle Med 2017;12:113-6. doi: 10.1177/ 1559827617745479.
23. Saki VY, Deniati EN, Besral B, Ekoriano M. The Role Of Individual And Community Factors On The Use Of Long-Term Contraceptive Methods (Mkjp) On Women Of Reproductive Age Couples In Indonesia 2018. The Indonesian Journal of Public Health 2021;16:492-50. Doi: 10.20473/ijph.v16i3.2021.492-502.
24. Putri TE, Pradanie R, Kusumaningrum T. Analysis Factors of the Intention of Postpartum Women using Long-Acting Reversible Contraceptive Based on the Theory of Planned Behavior.Pediomaternal Nurs J 2021;7:16-25. Doi: 10.20473/pmnj. v7i1.21498
25. Muji NE, Hargono A. The Relationship Analysis Between Husband’s Knowledge, Attitude And Practice for Maternal Health. J Berk Epidemiol 2014;2:118-29. DOI: 10.20473/jbe.V2I12014.118-129
26. Amanda SR, Armini NK, Kusumaningrum T. The Analysis of the Perceptions in Selecting Intrauterine Device on Women of ChildBearing Age Based on the Health Promotion Model Theory. J Comput Theor Nanosci 2021;18:334-8. DOI: 10.1166/jctn.2021.9523.