alexa Family Planning Service Utilization and Its Associated Factors among Married Women in Benchi-Maji Zone, Southwest, Ethiopia: Community-Based Crosssectional Study
ISSN: 2090-7214
Clinics in Mother and Child Health
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Family Planning Service Utilization and Its Associated Factors among Married Women in Benchi-Maji Zone, Southwest, Ethiopia: Community-Based Crosssectional Study

Tafesse Lamaro* and Niguse Tadele

Department of Nursing, College of Medicine and Health Sciences, Mizan-Tepi University, Ethiopia

*Corresponding Author:
Tafesse Lamaro
Department of Nursing, College of Medicine and Health Sciences
Mizan-Tepi University, Ethiopia
Tel: +251-912-92-22-71
Fax: +251-473-36-00-19
E-mail: [email protected]

Received date: March 03, 2017; Accepted date: March 23, 2017; Published date: March 31, 2017

Citation: Lamaro T, Tadele N (2017) Family Planning Service Utilization and Its Associated Factors among Married Women in Benchi-Maji Zone, Southwest, Ethiopia: Community-Based Cross-sectional Study. Clinics Mother Child Health 14:258. doi: 10.4172/2090-7214.1000258

Copyright: © 2017 Lamaro T, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

In Ethiopia, contraceptive use has doubled in the last five years, but women still bears an average of five children and 25% of married women want to space or limit their births but are not currently using contraception. So that, the purpose of this study was to assess Family planning services utilization and its associated factors among married women in Benchi-Maji Zone, Southwest, Ethiopia.

A community based cross sectional study was carried out to collect data from 801 randomly selected married women in the reproductive age group from six Kebles (lowest administrative unit). Pretested and structured questionnaire was used to collect data. The collected data was entered into a computer using Epi-Data version 3.0 then exported to SPSS for Windows version 20.0 for further analysis. Logistic regression was used to identify important predictors of family planning service utilization.

Out of 765 study participants, 82.61% were current users of at least one of Family Planning (FP) method and majority of them were using methods to space birth interval 452 (71.5%), to prevent unwanted pregnancy 198 (31.3%), followed by to promote health of born children 149 (23.6%). Knowledge about the benefits of FP and postnatal care follow up during their last delivery showed statistically significant associations with FP service utilization. Mothers who have mentioned at least one benefit of FP were about seventy times (AOR 71 95 % CI 25-202) more likely to ever use either of the FP methods and who have PNC follow up during their last delivery were about four times more likely (AOR 3.795 % CI 1.6-9.0) to use either of the FP methods in comparison with those mothers who haven’t attended for Postnatal care at all.

Most of the study participants prefer to use short-term family planning methods. It is important to promote longterm family planning methods to get a desire outcome among married women. Women are more receptive of FP during post-natal visits. It is desirable to utilize that visit for promotion of long-term FP methods among married women.

Keywords

Family planning; Benchi-Maji; Southwest; Crosssectional study; Mizan-Tepi University

Introduction

Pregnancy and childbirth are generally times of joy for parents and families. However, too early, too close, too many, or too late pregnancies pose adverse health consequences for the mother, child, and family [1-3]. A woman in a developing country is ninety seven times more likely to die as a result of pregnancy than a woman in a developed country [4]. The developing regions shares approximately 99% of the estimated global maternal deaths in 2015 and out of this, 66% were from sub-Saharan Africa [5]. In Ethiopia, the levels of maternal and infant mortality are among the highest in the world. In 2005, 676 maternal deaths have accounted for every 100,000 live births [6]. The probability of an adult woman dying from a maternal cause during her reproductive lifespan is about one in forty in Ethiopia [3].

Family planning is a low-cost yet effective way to lower maternal mortality by reducing the number of high-risk births [3]. The global report noted that unwanted, mistimed and unintended pregnancy is the most common cause of maternal mortality in developing countries and then, it could have been prevented by using family planning methods [7,8]. Using family planning could prevent as many as one in every three maternal deaths by allowing women to delay motherhood, space birth, avoid unintended pregnancies and abortion and stop childbearing when they reached their desired family size [3,9,10].

According to Demographic and Health Survey of Ethiopia (EDHS-2005), the knowledge of contraception has remained consistently high over the past five years with 88% of currently married women having heard of at least one method of contraception. However, actual contraceptive practice among women of reproductive age group remained very low [11]. Among currently married women, the trends in contraceptive use over the last fifteen years (2000 to 2014) have shown significant progress. There is a five-fold increase in the use of a method of contraception by currently married women, from 8% in 2000 to 42% in 2014. Also the contraceptive prevalence among currently married women increased by an impressive 46% in the last three years, from 29% in 2011 to 42% in 2014. Much of this increase is attributable to the sharp increase in the use of injectables. Use of injectables increased from 3% in 2000 to 31% in 2014. Equally impressive is the 49% increase in the use of injectables in just the last three years [12].

However, married women still bears an average of five children and 25% of them want to space or limit their births but are not currently using contraception even though increased family planning use could save approximately 13,000 mothers and more than 1 million children [13]. Despite the fact that family planning is critical for better improvement of maternal and child health; little is known about the use and factors influencing the use of this services in peripheral area in the region in general and particularly in Benchi-Maji zone. Therefore; the aim of this study was to assess Family planning service utilization and associated factors among married women in Benchi-Maji zone, southwest Ethiopia.

Methods and Materials

Study area and period

The study was conducted in Bench-Maji Zone, Southern region, Ethiopia. It is located in the southwest of Ethiopia with a population of about 760,313 (380,841 male and 379,472 Female) and 86% of population lives in rural areas. The majority of the inhabitants belong to Bench ethnic group, with small proportions of other ethnic origins [14,15]. The Zone has 218 health facilities (182 health posts, 35 Health centers, one General hospital and uncounted private clinics.) with one university and one health science college (Zonal Health Department Report). Most of the health institutions provide modern family planning services. The study was carried out from June 15, 2015 to August 15, 2015 [16].

Study design

The study employed cross-sectional study design where the data were collected at a specific point in time.

The source and study population

The study population is defined as all married women in their reproductive age group. The samples were randomly chosen from married women aged 15 to 49 years who was pregnant at least once in the last 2 years preceding study survey; irrespective of the pregnancy outcome.

Sample size determination

A sample size of 801 was determined from three randomly selected Districts in the zone by using a formula for estimation of single population proportion with the assumption of 95% confidence level, margin of error of 5% and taking proportion of Family planning 61.6% to obtain maximum sample size (19) and design effect of 2. In addition, non-response rate of 10% of the determined sample was added up on the calculated sample size and then, the total sample size of 801 was enriched.

Sampling procedure

Administratively, there are ten woredas (districts) in the Benchi- Maji zone with one administration town (Mizan-Aman Town). In order to have a fairly representative sample, selections of two Kebles (lowest administrative unit) were carried by using lottery method from each randomly selected three woredas namely Mizan-Aman Town, Shey-Bench and Menit-Shasha. Then, recording the number of households in six selected Kebles were carried. After that, calculated sample size was obtained by using probability proportional to the size of house hold in the six selected Kebles. From the six sampled Kebles, a total of 801 study samples were selected by using systematic sampling procedure. Lottery method was used for households with more than one eligible woman. In case, there were households with no eligible woman, the immediate next household was interviewed. Revisits of two times were made in case where eligible respondents were not available at the time of the survey. Regarding a women who have had more than one child, the most recent birth was taken.

Study variables

Dependent variables: Family Planning practice of married women.

Independent variables: Socio-demographic factors (age of mother, religion, ethnicity, occupation, education, Household economy), Obstetric History (Parity, gravidity, birth interval, mothers child experience, Pervious utilization of service) and Other factors related Access to mass media, health facility).

Data Collection Techniques and Procedures

Interviewer administered questionnaire was employed to collect the data. The questionnaires adopted and modified from EDHS and after reviewing different relevant literature. The questionnaire comprised of socio demographic characteristics (Age, ethnicity, education, Marital status, occupations etc.); reproductive history; knowledge and practice of family planning among married. The English version of the questionnaire was translated into Amharic languages for better understanding by the data collectors. The questionnaire then retranslated back to English to check for its consistency. Six diploma nurses who are fluently speaking local language were trained as interviewers and three BSc nurses were recruited for supervision of data collection. The interpretations of the questionnaires were checked by two people who are fluent in both languages. The training of diploma-nurse interviewers and BSc-nurse supervisors was carried within two days. The training was focused on explanation of the study purpose, interviewing techniques, data handling techniques, and ethical considerations during data collection. The interviewers and supervisors have had data collection guidelines. The supervisors were monitored data collection process by physical presence and through phone communication.

Data quality control

The pretest of the questionnaire was carried out in one of the kebles in BM (Benchi-Maji) Zone outside of the selected kebles that has similar socio-demographics characteristics with the people in both towns. 5% of total sample were used for pretesting and not included in original work. Based on the finding of pre-test, data collectors were reoriented and the questionnaire was modified as necessary. Data were collected by the trained six diploma Nurses from the selected Kebles of BM zone.

During data collection, socio demographic factors, obstetric history, health service barrier, and other factors related to FP utilization were assessed among study subjects. On the days of data collection, the principal investigator and supervisor was monitored the data collection process by checking its completeness of the data. Data was checked again for its completeness before data entry and the cleaning process was done by running simple frequency after data entry for its consistency.

Data processing and analysis

Each completed questionnaire was coded on pre-arranged coding sheet by the principal investigator to minimize errors. Data was entered into a computer using Epi-data version 3.0, 10% of the responses was randomly selected and checked for consistency of the data entry. Then printed frequencies were used to check for outlier and clean data. The data were cleaned accordingly and then, exported to SPSS Windows version 20.0 for further analysis. A computer frequency, % age, chi -square with p-value was used to describe the study population in relation to relevant variables. Analysis of data was done using two step logistic regression (bivariate and multivariate) to see the effect of the independent variables on the dependent variable by controlling confounders. Creating model for each outcome variables was carried. This statistical method was preferred because the dependent (outcome) variable is dichotomous, that is Family planning utilization and the independent variables are metric or categorical. Statistical significance was evaluated at 95% levels of significance. Tables and bar graphs were used to present data.

Ethical consideration

The study obtained ethical approval from the Research and community development support directorate of Mizan Tepi University (MTU). Support letter was written by MTU to the selected 2 woredas and 1 city administration and official permission was finally obtained from Bench Maji Zone Health Bureau, Menit Goldia woreda, Menit Shasha Woreda and Mizan Aman City administration health offices. Informed verbal consent was requested from each study participant after informing them about the objectives of the study where assurance of confidentiality was given and respondents were requested to give consent verbally after explaining objectives of the study.

Results

Socio demographic characteristics of married women in Benchi-Maji Zane 2015

About 801 married women were contacted and asked for consent, of whom 765 (95.51%) of them provided full information and used for subsequent analysis The mean age of mothers was 25.43 with the mean average monthly income of 1146.19 Ethiopian Birr with the average family size of 4 with ranging from 2 to 11. Majority of mothers were from Bench ethnic group 188 (24.6%) followed by Amhara 155 (20.3%) and Menit 148 (19.3%). Majority of mothers were followers of Protestantism 369 (48.2%) followed by Orthodox Christian 281 (36.7%). About 40% of them cannot read and write with majority of their husband (42.5%) attended primary school. About 73.2% of mothers were housewives with 36.3 % of their husbands were farmers. Majority of families have TV/Radio 483 (63.1%) in their house (Table 1).

Variable Frequency Percent
Maternal age n=765
15-19 21 2.7
20-24 319 41.7
25-29 271 35.4
30-34 109 14.2
>35 45 5.9
Ethnicity n=765
Bench 188 24.6
Amhara 155 20.3
Menit 148 19.3
Kaffa 140 18.3
Siltie 41 5.4
Oromo 33 4.3
Other* 60 7.8
Religion n=765
Protestant 369 48.2
Orthodox 281 36.7
Islam 96 12.5
Other** 19 2.5
Maternal Educational level n=765
Cannot read and write 306 40
Able to read and write 22 2.9
Primary school (1-8) 312 40.8
Secondary school 10-12) 80 10.5
College diploma and above 45 5.9
Maternal occupation n=765
House wife 560 73.2
Merchant 75 9.8
Farmer 60 7.8
Government Employee 44 5.8
Other*** 26 3.4
Husbands Educational level n=724
Primary school (1-8) 308 42.5
Cannot read and write 165 22.8
Secondary school (10-12) 111 15.3
College diploma and above 89 12.3
Able to read and write 51 7
Husbands occupation n=724
Farmer 263 36.3
Merchant 248 34.3
Government Employee 99 13.7
Daily laborer 85 11.7
Other*** 29 4
Availability of TV/Radio n=765
Yes 483 63.1
No 282 36.9
Income n=765
Lowest 194 25.4
Middle 204 26.7
Upper 367 48
Residence n=765
Urban 399 52.2
Semi urban 166 21.7
Rural 200 26.1
*Significant association **Traditional religion, Catholic, Hawariyat***Private business, Driver, Carpenter, Student, Religious leader, daily labourer

Table 1: Socio demographic characteristics of the married women on Family planning Services Utilization in Bench-Maji Zone, SNNPR, Ethiopia.

Knowledge and practice of family planning among married women in Benchi-Maji zone, southwest Ethiopia, 2015

On questions related to knowledge, almost all (96.3%) of mothers replied that they ever heard about family planning services mainly from health institution by health professionals, (73.0%). Majority (72.3%) mentioned it improves maternal health as a benefit of family planning. Besides, Injectable (99.2%) and Pills (97.2%) were mentioned by majority of study participants as family planning methods.

The respondents were asked whether they ever discussed about family planning methods with their husband and health professionals or not. About three fourth (76.0%) of them replied they have discussed with their husband and only 20 (2.6%) of them replied they haven’t ever discussed (Table 2).

Ever heard of family planning service n=765
  Frequency Percent
Yes 737 96.3
No 28 3.7
Source of information about FP methods n=737
Health institution/ care provider 538 73
Family/Relatives 117 15.9
Radio/TV 60 8.1
Other* 22 3
Type of FP they know n=737
Injectables 731 99.2
Pill 716 97.2
Implants/Norplant 575 78
IUDs 421 57.1
Condom 281 38.1
Female sterilization 162 22
Male sterilization 90 12.2
Spermicidal 18 2.4
Benefits of FP n=737
Improve maternal health 533 72.3
Improve child health 487 66.1
Increase wealth of the family 236 32
Increase wealth and prospective of the community 47 6.4
Increase national economic growth 40 5.4
Others 16 2.01
*From school (education) and more than one source

Table 2: Knowledge about and practice of family planning service among married Women of Bench-Maji Zone, Southwest Ethiopia, 2015.

Women were also asked whether they ever used any of modern family planning methods or not. About 92.42% of them ever used modern family planning methods and 92.79% of them used injectable and none of them used spermicidal and male sterilization. 82.61% of study participants were using either of family planning methods during the time of data collection mainly of injectable (76.9%) and 2 mothers were permanently sterile, none of them used condom, spermicidal and male sterilization as a method to plan pregnancy (Figure 1).

clinics-mother-child-health-Current-previous

Figure 1: Current and previous use of family planning methods among married Women of Bench-Maji Zone, Southwest Ethiopia, 2015.

Reason of using FP were also asked among current users and 71.5% of them used to space birth interval, 31.3% of them mentioned that to prevent unwanted pregnancy, 23.6% of them used because they wanted to promote the health of already born children, 5.5% of them used because of having enough children, 1.6% of them used because they can’t be pregnant again due to disease condition, and 5.7% of them used shortage of income to have more children.

Those who were not currently using FP were also asked again about reason and 17.3% of them said due to fear of side effects, 13.3% of them said due to plan to have more children, 4.0% of them said rumours they are not good, 2.7% of them due to husbands disapproval, 1.3% of them said lack of awareness, 1.3% of them due to the influence of important others, 1 (1.3%) of them due to religious prohibition, 1.3% of them said fear of infertility and menstruation did not returned, breast feeding, too early to start were among the mentioned reasons not to use.

The future intention of using family planning methods was asked and 80 % of them have a plan to use and 65.5% of them have intention to use injectable, 21.4% of them have intention to use implants, 9.5% of them have intention to use pill, 3.6% of them have intention to use IUDs in the future.

The association between independent variables and Family planning service utilization among married women in Bench-Maji zone, southwest Ethiopia, 2015

Bivariate analysis of the selected factors which includes maternal age, religion, maternal educational level, maternal occupation, maternal marital status, availability of TV/Radio, income quartiles, residence, knowledge of the benefits of FP, PNC follow up during their last delivery and maternal age during first pregnancy was performed [17,18]. Among the factors only maternal age during first pregnancy has not shown statistically significant association with FP utilization.

After adjustment with multivariate analysis only knowledge of the benefits of FP and PNC follow up during their last delivery maintained statistically significant associations FP service utilization. Among the factors which were associated with FP service utilization knowledge of the benefits of FP had shown extremely strongest associations with FP service utilization in which those mothers who have mentioned at least one benefit of FP were about seventy times (AOR 71 95% CI 25-202) more likely to ever use either of the FP methods and who have PNC follow up during their last delivery were about four times more likely (AOR 3.795% CI 1.6-9.0) to use either of the FP methods in comparison with whom mothers who haven’t attended for PNC at all (Table 3).

Variables Ever used FP COR (95%CI) P-value AOR (95%CI) P-value
No No (%) Yes Yes (%)
Maternal Age
15-24 23 6.8 317 93.2 1   1  
25-34 26 6.8 354 93.2 1.0(0.6,1.8) 0.967 1.8(0.8,4.2) 0.161
35-44 9 20 36 80 0.3(0.1, 0.7) 0.004* 1.1(0.3,4.2) 0.866
Religion
Protestant 39 10.6 330 89.4 1      
Orthodox 14 5 267 95 2.3(1.2,4.2) 0.012* 1.3(0.5,3.4) 0.53
Islam 2 2.1 94 97.9 5.6(1.3,23.4) 0.020* 3.5(0.5,24.7) 0.202
Other** 3 15.8 16 84.2 0.6(0.2,2.3) 0.479 0.3(0.04,2.6) 0.299
Maternal Educational level
Can’t read 41 13.4 265 86.6 1      
≤Primary 15 4.5 319 95.5 3.3(1.8,6.1) 0.000* 2.1(0.8,5.5) 0.141
≥Secondary 2 1.6 123 98.4 9.5(2.3,40.0) 0.002* 5.8(0.8,40.1) 0.076
Maternal occupation
House wife 40 7.1 520 92.9        
Gov’t 2 4.5 42 95.5 1.6(0.4,6.9) 0.518 1.4(0.2,13.3) 0.764
Merchant 2 2.7 73 97.3 2.8(0.7,11.9) 0.16 0.6(0.1,2.9) 0.511
Farmer 8 13.3 52 86.7 0.5(0.2,1.1) 0.094 1.1(0.4,3.5) 0.874
Other** 6 23.1 20 76.9 0.3(0.1, 0.7) 0.006* 0.3(0.1,1.7) 0.179
Availability of TV/Radio
No 36 12.8 246 87.2 1   1  
Yes 22 4.6 461 95.4 3.1(1.8,5.3) 0.651    
Income quartile
Lowest 26 13.4 168 86.6 1   1  
Middle 22 10.8 182 89.2 1.3(0.7,2.4) 0.424 1.0(0.4,2.3) 0.925
Upper 10 2.7 357 97.3 5.5(2.6,11.7) 0.000* 2.1(0.6,7.7) 0.254
Residence
Urban 17 4.3 382 95.7 1   1  
Semi urban 22 13.3 144 86.7 0.3(0.2, 0.6) 0.000* 0.4(0.1,1.3) 0.12
Rural 19 9.5 181 90.5 0.4(0.2, 0.8) 0.013* 1.5(0.4,5.4) 0.531
Maternal age during first pregnancy
15-19 31 9.3 303 90.7 1      
20-24 22 5.9 354 94.1 1.7(0.9,2.9) 0.085    
25-34 5 9.1 50 90.9 1.0(0.4,2.8) 0.964    
Mentioned benefit ofFP
No 28 58.3 20 41.7 1      
Yes 30 4.2 687 95.8 32(16,63) 0.000* 71(25,202) 0.000*
PNCfollow up
No 48 12.9 325 87.1 1      
Yes 10 2.6 382 97.4 5.6(2.8,11.3) 0.000* 3.7(1.6,9.0) 0.003*

Table 3: The association between independent variables and FP service utilization among married Women of Bench-Maji Zone, southwest Ethiopia, 2015.

Discussion

The aim of this study was to identify determinants of family planning service utilization in Benchi-Maji Zone, Southwest Ethiopia. Many reasons were mentioned among users for low utilization of FP methods in Ethiopia [19]. Therefore, understanding the various factors contributing to low family panning utilization is vital. In our study, majority, 737 (96.3%) of respondents have ever heard about family planning services and two third of them get information about the methods from health facility. This result is similar with other studies conducted in Mekele, Adigrat and Debre Markos town [20-22]. In this study, 707 (92.42%) of respondents ever used either of the modern FP methods. This finding is consistent with several studies [18-20].

On contrary, this result is higher than population based study conducted in Mojo Town [16]. Possible reason for this discrepancy might be difference in study population. This study also focused on married women rather reproductive age group women. In our finding, majority of them ever used injectable 656 (92.79%) and none of them used spermicidal and male sterilization and 82.61% of them were using either of FP methods during the time of data collection; mainly of injectable 76.9% and 2 mothers were permanently sterile, none of them were using condom, spermicidal and male sterilization as method to prevent pregnancy. The finding of this study coincide with study conducted in Mekele city and Assosa district among married women; majority of them ever used and have been using injectables and pills [19-21] and this was too much higher than a population based study in Mojo town which reported that from 551 respondents nearly 34% of them have ever practiced one form of FP methods during their life [16] and the study from South Central Ethiopia in which Current contraceptive prevalence rate was 25.4% (95% CI: 24.2, 26.5) [17] and this difference mainly might be attributed to expansion of health facility, increased Information, Education and communication (IEC) on FP methods which creates awareness and increased service seeking behavior in this study. Unlike the above disparities; the finding of this study yields closer result to a study conducted in the Dangila and Assosa zone [18,19]. In our study, majority 452 (71.5%) of them used FP to space the birth interval and 198 (31.3%) of them mentioned that to prevent unwanted pregnancy. This was in line with study conducted in Assosa district [19]. Fear of side effect and wanting more children were major reason for not using FP methods in this study. This is consistent with other studies [16,20].

According to this study among the factors which were associated with FP service utilization, knowledge of the benefits of FP had shown extremely strongest associations with FP service utilization in which those mothers who have mentioned at least one benefit of FP were about seventy times (AOR 7195% CI 25-202) more likely to ever use either of the FP methods and who have PNC follow up during their last delivery were about four times more likely (AOR 3.795% CI 1.6-9.0) to use either of the FP methods in comparison with mothers who haven’t attended for PNC at all. This result is similar with a study done in Mojo town in which age of the mother, age at first marriage, marital status, income, occupation of women and occupation of husbands were not independently associated with FP utilization [16].

Factors which were not associated with FP service utilization were shown to have an association as a South Central Ethiopia study in which the odds of current use of family planning was 2.3 (95% CI: 1.66, 3.18) times higher among urbanites compared to highlanders and there was a positive association between contraception and educational status of women. Women with primary and secondary level of education were about 1.32 (95% CI: 1.12, 1.56) and 1.99 (95% CI: 1.38, 2.88) times respectively more likely to use FP compared to their uneducated counterparts [17].

Conclusion

In this study, majority of mothers 737 (96.3%) replied that they have ever heard about family planning services. Injectable and Pills methods were used by majority of study participants. Out of Current 632 users, majority 452 (71.5%) were using the methods to space the birth interval followed by 198 (31.3%) to prevent unwanted pregnancy. Out of observant who have a plan to use FP methods in future, majority of observant have intention to use injectable. Postnatal care service utilization during their last delivery and awareness about FP methods has showed statistically significant associations with Family planning service utilization. Most of the study participants prefer to use short-term family planning methods. It is important to promote long-term family planning methods to get a desire outcome among married women. Women are more receptive of FP during postnatal visits. It is desirable to utilize that visit for promotion of long-term FP methods among married women.

Limitations of the study

The drawback of this study was the cross-sectional nature of the data that could obscure the causal effect relationships of different factors. In addition, selection and recall bias were another probable limitation of this study.

Acknowledgements

The authors are indebted to all women who participated in this study. The authors would like to thank Health Department of Woredas (Districts). We would like to acknowledge Institute of research and community support office of Mizan-Tepi University, for their funding in order to run all steps of this research, without their support this research never reaches to this level.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

Tafesse Lamaro (TL) was conceived the study, conducted data collection, participated in analysis and writing of the manuscript.

Niguse Tadele (NT) was participated in data collection, analysis and writing of manuscript. All authors read and approved the final manuscript.

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