Study area and setting
Located between the Caribbean Sea and the North Atlantic Ocean, the Republic of Haiti has an area of 27,750 km2, and an estimated population of 11.4 million of which 60.5% are under 30 years old. Slightly more than half (50.5%) of people are women, 53.2% of whom are aged 15–49 (i.e. they are of childbearing age) . Nearly 60% (58.4%) of the Haitian population lives in urban areas . Moreover, Haiti is one of the poorest countries in Latin America and the Caribbean region: the poverty rate is estimated at 58.5% (40.6% in urban vs 74.9% in rural areas) .
This present research used data from the most recent cross-sectional Haitian Demographic Health Survey (HDHS), a national level survey conducted over 5 months from November 2016 to April 2017, and implemented by the Haitian Institute for Children (HIC) in collaboration with the Haiti National Bureau of Statistics (HNBS), and the Ministry of Public Health and Population (MPHP). The survey gathered information on household population and characteristics, fertility, marriage, sexual activity, nutrition, malaria, HIV-AIDS, maternal and child health, adult and childhood mortality, women’s empowerment, domestic violence, and other health-related issues. Four questionnaires were used for the data collection: Household Questionnaire, Women’s Questionnaire, Men’s Questionnaire and Biomarker Questionnaire. The Women dataset which contains information on sexual and reproductive health of all women of childbearing age was used for our study. Further information about the 2016/17 HDHS is provided in the full report .
The 2016/17 HDHS followed a two-stage sample design and was intended to allow estimates of key indicators at the national level as well as for urban and rural areas and each of Haiti’s 10 administrative regions (Ouest, Sud, Sud-Est, Grande-Anse, Nippes, Nord, Nord-Ouest, Nord-Est, Centre, and Artibonite). In the first stage, 450 enumeration areas (EAs) or clusters were selected with probability proportional to sample enumeration area (SEA) size. The second stage involved a systematic selection of households from the selected EAs. In the 450 EAs, 13,451 households were occupied at the time of data collection of which 13,405 were successfully interviewed. Further, 14,525 women of childbearing age (15–49 years) were eligible to participate and 14,371 were successfully interviewed, yielding a response rate of 98.9%. The men’s survey was conducted in two-thirds of the sample households, and all men aged 15–64 who were either permanent residents of the selected households or visitors who stayed in the households the night before the survey in these households were included. Out of a total of 9995 men who were identified, 9795 were successfully interviewed, yielding a response rate of 98.0%. Finally, in one-third of the households, women aged 50–64 and men aged 35–64 were also eligible, but only for certain aspects of the survey. In this subsample, 2125 men aged 35–64 were identified and 2091 were successfully interviewed, yielding a response rate of 98.4%. As for women aged 50–64, 1150 were eligible, and 1142 were successfully interviewed (99.3% of response rate) .
The interviewers (recruited and trained by ICF Institutional Review Board, HIC, HNBS, and MPHP staffs), conducted face-to-face interviews in the selected households from eligible women and men. The data was collected via the Computer Assisted Personal Interviewing (CAPI) data collection system developed by the DHS Program. The tablet PCs were used to record the responses obtained .
All women of childbearing age (15–49 years) successfully interviewed constitute our study population.
Study variables and measurements
The outcome variable of this study was having correct knowledge of ovulatory cycle (KOC), which was recoded and dichotomized. When collecting data from the women, they were asked “when do you think a woman has the greatest chance of becoming pregnant?”. The different responses were: “during her period", "after period ended", "middle of the cycle", "before period begins", "at any time", and "I don’t know". Respondents who indicated fertile period is at the middle of the menstrual cycle were categorized as having correct KOC while respondents who answered the question as fertile period is “during her period”, “after period ended”, “before period begins”, “at any time”, and “I don’t know” were categorized as “no”. This variable coding is provided by the HDHS .
The covariates were divided into three groups socio-demographic variables which included age (“less than 25 years”, “25–29”, “30–34”, “35–39”, “40 and above”), place of residence (“urban” and “rural”), region (“Aire Métropolitaine de Port-au-Prince”, “Reste-Ouest”, “Grand Sud”, “Grand Nord”, “Artibonite”, “Centre”, and “Grand’Anse/Nippes”), religion (“no religion”, “christian”, and “voodoo or others”), respondent's education level (“primary or less”, “secondary”, and “higher”), marital status (“never in union”, “in union”, and “widowed/divorced/separated”), number of living children (“no children”, “1–2”, “3 or more”), husband/partner’s education level (“primary or less”, “secondary”, and “higher”); socio-economic variables which included wealth index (“poor”, “middle”, and “rich”) and currently working (“yes” and “no”). The other independent variables were current contraceptive use by method type (“no method”, “traditional method”, and “modern method”), fieldworker visit in last 12 months (“yes” and “no”), and exposure to mass media family planning messages (“yes” and “no”). Exposure to mass media family planning messages was a composite variable created by combining four variables: “have heard about family planning messages on radio in last few months”, “have heard about family planning messages on TV in last few months”, “have heard about family planning in newspaper/magazine in last few months”, and “have heard about family planning by text messages on mobile phone in last few months”. In the Women dataset, these four variables were coded as “yes”, and “no”. After examining the frequency distribution of the responses, we coded it as “yes” if a woman heard family planning messages through at least one of these mass media, and “no” if she did not hear family planning messages through any of the mass media. Selection of these covariates was based on previous studies [1, 18,19,20,21].
Descriptive statistics were generated to summarize the data and the results were presented as proportions (%). Bivariable analyses (Pearson’s chi-square) were conducted to assess the associations between the outcome variable and each covariate. To identify determinants of KOC, a multi-variable analysis (binary logistic regression) was performed and adjusted odds ratios (AOR) at 95% confidence intervals (95% CI) were estimated. All analyses were weighted (HV005/1,000,000) to get unbiased estimates . Statistical analysis was done in STATA 14 software using svy command to adjust for the complex sampling structure of the data . A significance level of 0.05 was considered.
This study is based on a secondary analysis of publicly available data (https://dhsprogram.com/data/available-datasets.cfm); therefore, no ethics approval was required from our institutions. However, to obtain permission to access these datasets, we registered and sent a request (on May 3, 2022) including the objective of our study to the managers of the DHS program via their online platform. Two days later, we received approval to access and download the data files. According to the 2016/2017 HDHS report, during DHS data collection, all participants gave their informed consent, and the data were anonymized .