Nigeria is the most populous country in Africa, with more than 88 million people; it also has a high annual rate of population growth (3.5%) and a total fertility rate of 6.0 lifetime births per woman.1 Additionally, the country has relatively high levels of infant mortality (104 infant deaths per 1,000 live births) and maternal mortality (800 maternal deaths per 100,000 live births).2 In response to these and other serious demographic and health issues, the Nigerian government put into effect a national population policy in 1989 that called for a reduction in the birthrate through voluntary fertility regulation methods compatible with the nation's economic and social goals.3
During 1992-1993, an information, education and communications campaign was launched to change Nigerians' attitudes toward family planning, and to thereby increase their contraceptive use. The campaign was based on evidence that family planning messages relayed through the mass media can influence contraceptive behavior. For example, in Nigeria, one-quarter of new clients attending a family planning clinic identified a television campaign as their source of referral. Similarly, a mass media effort in the Philippines promoting sexual responsibility substantially increased requests for contraceptive information among adolescents.4 Other studies have shown that exposure to a mass media family planning campaign increases contraceptive use.5
Several studies have reported changes in Nigerians' knowledge of and attitudes toward family planning.6 These studies, however, did not examine the association between attitudes toward contraception and its use. In the 1981-1982 Nigerian Fertility Survey, only 34% of all women reported that they had heard of any family planning method. By 1990, when the Nigerian Demographic and Health Survey was conducted, the proportion of women who knew of any contraceptive methods had increased by about one-third, to 46%, and the proportion of women who knew of specific methods also had grown.7 Furthermore, 41% of married women who knew of a contraceptive method had discussed family planning with their husbands. Although the majority of them had discussed the topic with their husbands only once or twice, a substantial proportion had done so more often. Seventy-one percent of married women who knew a family planning method said that their husbands also approved of family planning.
This article investigates the association between Nigerians' attitudes toward family planning and their contraceptive behavior. To ascertain what gains the family planning campaigns in Nigeria have made and what factors motivate contraceptive use, we set out to answer the following question: Do positive attitudes toward family planning affect contraceptive use? The answer will help policymakers and program planners determine what issues need to be stressed in the design of future family planning awareness campaigns in Nigeria.
This article presents data on contraceptive use, knowledge, attitudes and practices in Nigeria, obtained from a national survey conducted between 1992 and 1993. A total of 1,540 men and women were selected for interview, using a multistage sampling technique. Respondents were residents of the state capital and a rural community in each of three states—Enugu and Nike in Enugu State, Kano and Rimin Gado in Kano State and Lagos City and Ayobo in Lagos State.
Provisional data from the 1991 census reported populations of 3.2 million, 5.6 million and 5.7 million in Enugu, Kano and Lagos states, respectively. Kano State is in the northern part of the country and has a predominantly Muslim population. The majority of the residents of the capital city, Kano, are Hausas, and the city's minority Christian population is concentrated among its younger, educated and migrant residents. Rimin Gado is approximately 40 kilometers from Kano and is a moderately sized farming community of approximately 2,000 people.
Enugu State is in the eastern part of the country, and the city of Enugu is now the country's capital. The indigenous population is predominantly Ibo, but other groups also live in the state. Christianity is the dominant religion. Nike is an agrarian community on the outskirts of Enugu.
Until recently, Lagos, which is located on the southwestern coast of Nigeria, was the capital city of Nigeria. The indigenous population is mainly Yoruba, but Ibos, Hausas, Fulanis, Kanuris and other ethnic groups from the eastern and northern parts of the country have settled in the city over the years. Christianity and Islam are the dominant religions. Ayobo, a farming community with a population of more than 4,000 people, is on the outskirts of the city.
The three urban centers were stratified into four residential areas—elite, mixed (both migrants and nonmigrants), migrant working class and indigenous—and each of these was further divided into blocks. The researchers selected two blocks, within which 180 households were randomly selected; the first 90 were the main sample and the second 90 a backup. The rural areas were not stratified because each one was relatively homogenous; households were selected by systematic random sampling. In each of the three villages, 150 men and women were interviewed. Within each urban and rural household, the husband and wife and all adolescents were interviewed. When there was more than one wife, a lottery was drawn to determine which one would participate.
In all, 1,540 interviews (753 men and 787 women) were completed. The analysis in this article is limited to the 927 married respondents, because those who were unmarried may not have been sexually active and therefore may not have needed to practice contraception.
Respondents were asked to rate their level of agreement with 26 attitudinal statements describing the impact of family planning on the family, individual health and well-being, and marital relations and stability, on a scale from one (strongly agree) to five (strongly disagree). The statements were largely based upon the themes of the information, education and communications campaign. For example, the respondents were asked to rate their level of agreement with the statements: "Family planning helps a couple to become responsible parents" and "Family planning leads to a broken home."
Factor analysis was used to examine the interrelationships among explanatory variables. Factor analysis refers to a variety of statistical techniques whose common objective it is to represent a set of variables in terms of a smaller number of hypothetical factors.8 The basic assumption of factor analysis is that underlying dimensions or factors can be used to explain complex phenomena. The mathematical model for factor analysis is similar to a multiple regression equation, and each variable is expressed as a linear combination of factors that are not actually observed.
The factor analysis of the 26 attitudinal statements was conducted using the principal component method. The analysis was disaggregated by gender. The criterion for the number of factors to be extracted was that the eigenvalue of each factor had to be equal to or greater than one. Extracted factors were then rotated by the varimax method. Each of the 26 statements was assigned to the factor with which it had the highest correlation.
After some variables were extracted from the complex attitudinal statements, the variables' effect on the respondents' current contraceptive use was examined. Because the analysis is based on current use, the dependent variable is dichotomous. Therefore, a logistic regression model was used to examine the effect of the factor-analyzed family planning attitudes on current contraceptive use. The dependent variable for each observation takes on a value of one if the respondent is currently using contraceptives and a value of zero if the respondent is not. The independent variables are the factor scores and some other theoretically relevant variables, such as education, place of residence, state of origin, ethnicity, occupation, spousal communication and social support.
About one-half of respondents were aged 20-34, and one-fifth were aged 45-49 (Table 1). More than 40% of the male respondents were aged 45-49; in contrast, most of the female respondents were younger. Among the men, 43% reported having a primary school education and 32% a secondary school education. Among the women, 37% reported having a primary school education and 22% a secondary school education. More than one-third of the male respondents were farmers, and another third were involved in professional or administrative occupations; almost four in 10 of the female respondents were engaged in artisanal jobs such as weaving and sewing, and another one-third of women held clerical or sales positions. More than two-thirds of respondents were either Ibos or Hausas, while one-quarter were Yorubas. Almost half were Muslim, one-quarter were Christian and the remainder belonged to other religious groups.
Contraceptive Knowledge, Attitudes and Use
Although the majority of respondents reported knowing of a contraceptive method (76%), only 28% were currently using one, and fewer than half (47%) reported ever having used one (Table 2). A smaller proportion of men (42%) than women (50%) had ever used contraceptives, and women were more likely than men to have ever used a traditional method or a modern method. (It is not possible to say whether the women used these methods with their spouses, since the study was not couple-based.)
Respondents were generally supportive of family planning, although overall women were more likely than men to agree with the positive attitudinal statements (Table 3). When asked whether practicing contraception allows parents to prepare for children, 63% of men agreed, compared with 78% of women. Moreover, while 72% of female respondents agreed that contraceptive use will help improve one's standard of living, only 40% of the male respondents did so. Fewer than three-quarters of men, but more than four-fifths of women, agreed that family planning helps a woman regain her strength between pregnancies and that it protects the health of mothers.
A large proportion of both male and female respondents (77% and 86%, respectively) agreed that a daughter should be allowed to complete school before marriage. Fewer men than women agreed that early marriage and childbearing can damage a girl's health (57% vs. 67%).
Attitudes toward family planning and marital relations were less positive among men than among women. Although roughly one-fifth of respondents overall supported the statement that a couple practicing family planning will have conflict in their marriage, 25% of the men agreed with it. Female respondents (55%) were also more likely than males (40%) to agree that having a large family strains a couple's relationship.
Women were far more likely than men to agree with the statement that men should share in the responsibility for family planning. While almost three-quarters of women registered a high level of support for men playing a role in family planning, only one-third of the men did.
Of the 26 statements examined in the factor analysis, five were associated with no factor—an indication of their irrelevance.* Each entry in Table 4 shows the relative effect of the factor on current contraceptive use; these values are referred to as factor loading. Table 4 also indicates the communality of each variable—that is, the proportion of the variance in the dependent variable that is explained by the attitudinal statement.
Table 4, which shows the sorted, rotated factor loadings for male and female respondents combined, indicates that the extracted factors explain about 59% of the variance. Factor 1, which associates family planning with health benefits and a better standard of living, represents respondents' positive attitudes toward family planning. It is the principal factor, has an eigenvalue of 9.6 and explains 46% of the variance in contraceptive practice. The factor correlates favorably with such statements as "child spacing protects the health of mothers" and "practicing family planning will create a better society."
Factor 2 correlates highly with the statements that measure the perceived association between contraceptive use and conflict in the home, such as "the practice of family planning will cause a loss of confidence between a husband and a wife." It has an eigenvalue of 1.7 and explains about 8% of the total variance. Factor 3 correlates with the statement that a daughter should be able to complete school before marriage. It has an eigenvalue of 1.1 and explains only 5% of the variance.
For the married men, Factor 1 has an eigenvalue of 11.2 and explains 53% of the total variance in the dependent variable, while Factor 2 has an eigenvalue of 1.8 and explains 9% of the total variance. These two factors explain 62% of the total variance for married male respondents. However, Factor 3 was not relevant for the men. All three factors were extracted for the married women (as for all respondents). These three explain 53% of the total variance in current use of contraceptives.
The estimated factor scores were then used in a logistic regression analysis along with selected socioeconomic factors, such as education, place of residence, ethnicity, occupation, spousal communication and social support variables. (The latter were measured using—as a proxy—responses to the question asking whether the respondent's spouse, closest friend, religious group, doctor or mother-in-law approved or disapproved of contraceptive use.)
Analysis was done for all respondents combined and later was disaggregated by gender. All variables were used in the general model; the forward stepwise method was then used to select critical predictor variables. Table 5 presents results both of the general model and of the final model.
Among the chief predictors of contraceptive use for all respondents combined were education, religion, approval of family planning, media exposure, spousal communication and approval and agreement that female education should be encouraged (Factor 3).
Respondents who approved of family planning were two times as likely to be using contraceptives as those who disapproved. Those who agreed strongly that a girl should finish her education before marriage (Factor 3) were almost twice as likely as those who did not to be practicing family planning.
The analysis also highlighted the importance of significant others in the decision to use contraceptives. For example, spousal approval and communication with one's spouse were significant variables: Respondents with spouses who approved of family planning and those who had discussed family planning issues with their spouses were more likely to be contraceptive users.
Dissaggregation of the analysis by gender indicates that for the men, the critical variables that influence the probability that they will use family planning were their religion and ethnicity. Other predictors were family planning approval, media exposure, place of residence and spousal approval and communication.
The predictor variables for the female respondents were age, education, ethnicity, family planning approval, media exposure, communication with their spouse and his approval of family planning, and the social support of others. Women who agreed strongly with the statement that the practice of family planning breeds conflict in the home were 37% less likely than those who disagreed to use family planning. In addition, those who support female education and discourage early marriage were three times as likely to practice contraception as those who do not.
One would expect Factor 1 to have shown a positive effect, but it had a negative impact instead. This could have been the result of an interaction with other variables, so the analysis was rerun using only Factors 1, 2 and 3. When this was done, the three factors all had the expected effect on contraceptive use (Table 6). Thus, respondents who associated family planning with health benefits and an improved standard of living (Factor 1) were more likely than those who did not to be practicing contraception. Conversely, those who agreed that family planning breeds conflict in the home (Factor 2) were less likely than those who disagreed to be using contraceptives. This is often the reason men and women in developing countries give for not practicing family planning. For example, some men believe that its use will encourage infidelity on the part of their wives. Contraceptive use was more likely among respondents, particularly females respondents, who agreed that family planning encourages delayed marriage (Factor 3) than among those who disagreed.
These findings demonstrate that people's perceptions of family planning affect whether they will use it. Those who think that practicing contraception provides health benefits are likely to use a method, as are those who perceive that family planning will help them to improve their standard of living. Furthermore, this analysis suggests that there is an association between attitudes toward family planning and contraceptive use.
The study also shows the impact social support can have on contraceptive use. Individuals who have an influence on the respondents had a positive effect on their contraceptive behavior. Therefore, it is important to identify those who can act as social change agents and to increase their support for contraception. Their endorsement of family planning may thereby increase contraceptive use among their family and other community members. Spousal communication, too, is an important predictor of contraceptive use and must also be considered in family planning service delivery. Finally, the association between ethnicity and contraceptive use indicates the importance of considering the social and cultural implications of family planning service delivery.
If we accept the factor structure as valid, then Nigerians' increased contraceptive use may be attributable to their changed perceptions of family planning, brought about both by the government's information, education and communication campaign and by the country's economic hardship. Thus, family planning awareness programs have had and may continue to have an influence on Nigerians' contraceptive behavior. The importance of intensifying these programs, especially in rural areas, cannot be overemphasized.