Study area and setting
The Gurage zone is located in the central and southeastern mountainous area of Ethiopia in the Southern Nations, Nationalities and Peoples Region (SNNPR). It consists of 13 Woredas (Fig. 1), of which, GPSDO works in nine Woredas involving 250 kebeles (The smallest political administrative units). It is implementing an integrated package of environmental protection, livelihood improvement, health and education interventions (PHE integration) in 45 kebeles located within four Woredas: Cheha, Getta and Mehur-Aklil. The population of the zone is 1.4 million, of which 90 % live in rural areas. The Gurage Zone is one of the most densely populated zones in Ethiopia, with the maximum density reaching 441 persons per square kilometer. The national average for Ethiopia is 281 persons per square kilometer, while the average for SNNPR is 106 persons per square kilometer. The primary occupation in the zone is subsistence farming. As a result of the high population density and traditional farming practices, there is extensive soil erosion in the area. Crop yields have also declined as the quality of the soil has declined due to overuse. This environmental degradation contributes to food insecurity in the zone. Few families own livestock and most farm plots are less than one acre. According to the zonal agricultural department, only 10 % of families have at least one complete meal per day. Many husbands also migrate to the cities and have business there and come back to their rural wives on the Meskel Holiday, which is celebrated in September. The Woreda health offices use the holiday an opportunity to distribute family planning services to prevent unwanted pregnancies.
Study design and sampling techniques
A comparative cross-sectional study was carried out during October, 2012 to determine the FP outcomes in PHE and non-PHE Woredas in Gurage Zone. Detailed background data were collected from married couples using structured questionnaires. The study involved a total of 960 married women of in the reproductive age (15–49 years old) selected using a simple random sampling technique stratified by the PHE and non-PHE areas. The sample was further allocated to kebeles in each of the two Woredas in the PHE (Mihur Aklil) and non-PHE (Gumer) Woredas. Epinfo stat calculator was used to determine the sample size for the study using a formula for the estimation of comparative cross-sectional study with the following assumptions:
$$ n=\frac{{\left(Z\frac{\alpha }{2}\sqrt{\left(1+\frac{1}{r}\right)P\left(1-P\right)}+Z\frac{\beta }{2}\sqrt{P1\left(1-P1\right)+\frac{P2\left(1-P2\right)}{r}}\right)}^2}{{\left(P1-P2\right)}^2}\times 2\left(\mathrm{design}\ \mathrm{effect}\right) $$
Power (1- ß) =95 %
Zα/2=Standard normal variable at 95 % confidence level (1.96)
P1 = Expected CPR in non-PHE Woredas (P1) =33.46 % [11].
P2 = 43 % with an assumed odds ratio of 1.5,
R = Ratio of sample population from PHE to non-PHE Woredas (1:1).
This gives a minimum sample size of 480 married women. Multiplying this by a design effect of 2 for the cluster sampling gives a final sample size of 960 married women.
For the in-depth interview 22 key informants pooled from different stakeholders were purposively selected from GPSDO staff, Health Extension Workers (HEWs), development agents (DAs), Community Based Reproductive Health Agents (CBRHAs), Woreda officials from relevant sectors such as health, agriculture, forestry workers education and students both in PHE and non-PHE Woredas.
Within each Woreda, kebeles were randomly selected as community survey sites. To the extent possible, the Woredas and kebeles were matched with similar demographic characteristics to make a fair comparison across PHE and non-PHE sites. The total sample from the quantitative study was allocated to the different Woredas in the PHE and non-PHE areas proportional to the size of their population. Within each kebele, the study subjects (married women 15–49 years) were selected using simple random sampling technique (Fig. 2).
Measurement
The study generated data used to compare FP outcomes in PHE and non-PHE Woredas. Emphasis was given to indicators that are used for the GPSDO project outcomes which include indicators taken from the MEASURE Evaluation family planning and reproductive health indicators [12].
Variables including: contraceptive prevalence rate (CPR), percent of women of reproductive age who have heard of at least three methods of FP, percent of the population who knew at least one source of modern FP services or supplies, number of new acceptors to modern contraceptives (women who used modern contraceptive methods for the first time in their life during the last 1 year), percent of men who support the use of modern contraception for themselves or their partners were captured as measures of family planning outcomes.
The questionnaires focused on knowledge, and practices related to FP to determine if there is a difference in FP outcomes between the PHE and the comparison vertical FP sites. Questions in the survey were based on items adapted from other surveys such as DHS.
A survey questionnaire was developed and administered by data collectors after pre-test and necessary modifications were made. The data collectors and supervisors were trained on data collection instruments, procedures and study objectives and briefed on any changes made to the survey tool before they began data collection. For the actual survey, households were selected randomly using the list of households in kebele administration as a sampling frame. Within each household, married women of reproductive age were interviewed. Interviews were conducted by trained interviewers fluent in the local language (Guragigna).
Both woreda level and community level key informants were interviewed on the modalities of integration of family planning with conservation activities using semi-structured interview guide. All activities were conducted under close supervision of PHE Ethiopia Consortium staff in order to ensure quality and appropriateness as well as to build the capacity of PHE Ethiopia consortium staff in conducting high quality research projects.
Operational definitions
PHE-Woreda
The PHE Woreda is Mihurna Aklil Woreda where family planning services are given integrated with environmental conservation activities using both community level volunteers, campaign and in schools and using students as a medium to educate their parents on population health and environment.
Non-PHE Woreda
Non- PHE Woreda (Gummer) is the woredaoreda where, family planning services are delivered as separate services vertically with no much emphasis on the integration with the environment and health.
Data analysis
Data from the community survey were analyzed using SPSS for windows version 16.0. First descriptive statistics were provided using means and proportions. Bivariate logistic and linear regressions were performed to select variables that are candidates for entry into the adjusted model. Multivariable linear regression model was fitted to identify variables that have an independent effect on FP knowledge. A second multivariable logistic regression was performed to identify independent predictors of current FP use. In order to avoid the confounding effect of the Meskel Holiday family planning campaigns, logistic regression model was fitted for non-new acceptors of family planning. Statistical significance was declared at P < 0.05.
Qualitative data obtained from in-depth interview was grouped under themes; color coded and analyzed using thematic frameworks. The results were presented in triangulation with the quantitative results using direct quotes as illustrations.
Ethical considerations
Verbal consent of the study participants was requested before data collection. Permission was granted from the Gurage Zonal and respective woreda health offices to conduct the study in the respective woreda. The study protocol was ethically reviewed and approved by the Jimma University Ethical Review Committee. All information obtained is be kept anonymous. For this reason none of the personally identifiable information will not be used in the presentation of the findings in any form.